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MINUTES - 02281989 - 1.15
APPLICATION TO FILE LATE CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA BOARD ACTION Application to File Late Claim ) NOTICE TO APPLICANT February 2.3 , 1939 Against the County, Routing ) The copy of this document mailed to you is your Endorsements, and Board Action.) notice of the action taken on your application by (All Section References are to ) the Board of Supervisors (Paragraph III, below), California Government Code.) ) given pursuant to Government Code Sections 911.8 and 915.4. Please note the "WARNING" below. Claimant: SUSAN W, BUSBY County Counsel c/o Law Office of Maryanne Britten Attorney: Salvio Pacheco Square JAN 2 7 1989 2151 Salvio St , -#399 Address: Concord, CA 94520 Martinez, CA 94553 Amount: $2-) 920 .,00 By delivery to Clerk on January 23 , 1989 hand del , Date Received: January 23 , 1939 By mail, postmarked on no envelope I. FROM: Clerk of the Board of Supervisors TO: County Counsel Z . Attached is a copy of the above noted Application t File Late Claim. DATED: January 27 , 1989 PHIL BATCHELOR, Clerk, By - Deputy T. Na 1 1 II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ) The Board should grant this Application to File Late Claim (Section 911.6). ( � The Board should deny this Application to File Late C m tion 1.6). DATED: "2-� VICTOR WESTMAN, County Counsel, B Deputy III. BOARD ORDER By unanimous vote of Supervisors present (Check one only) This Application is granted (Section 911.6). ( ) This Application to File Late Claim is denied (Section 911.6). I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. DATE: FEB 2 8 1989 PHIL BATCHELOR, Clerk, By Deputy WARNING (Gov. Code §911.8) If you wish to file a court action on this matter, you must first petition the appropriate court for an order relieving you from the provisions of Government Code Section 945.4 (claims presentation requirement). See Goverment Code Section 946.6. Such petition must be filed with the court within six (6) months from the date your application for leave to present a late claim was denied. You may seek the advise of any attorney of your choice in connection with this matter. If you want to consult an attorney, u should do so immediately. IV. FROM: Clerk of the Board T0: 1 County Counsel 2 County Administrator Attached are copies of the above Application. We notifed the applicant of the Board's action on this Application by mailing a copy of this document, and a memo thereof has ben filed and an.dorsed on the Board's copy of this Claim in accordance with Section 29703• �a� of y MAR 2 1989 ���� 'ed,a eoZte ZeZW, DATED: PHIL BATCHELOR, Clerk, cffy -�-�� Deputy V. FROM: 1 County Counsel 2 County Administrator TO: Clerk of the Board of Supervisors Received copies of this Application and Board Order. DATED: 'county Counsel, By County Administrator, By APPLICATION TO FILE LATE CLAIM The Board of Supervisors Contra CetrkoahehBoard Costa and County Administration Building County Administrator .651 Pine St., Room 106 (415)646-2371 Martinez, California 94553 County Tom Powers,1st District Nancy C.Fanden,2nd District Robert I.Schroder,3rd District �?•- o, Sunne Wright McPeak 4th District Tom Torlakson,5th District -e6 rN March 7, 1989 Maryanne Britten, . Attorney Salvio Pacheco Square 2151 Salvio Street, Suite 399 Concord, California 94520 Dear Ms. Britten: Subject: Susan W. Busby In reviewing the minutes of February 28, 1989, we found that the action of the Board of Supervisors was incorrectly recorded on the Application to File a Late Claim presented on behalf of Susan W. Busby. Enclosed is a corrected copy of the Board order denying the Application of Susan W. Busby. We regret any inconvenience this may have caused. Yours very truly, Jeanne O. Maglio Chief Clerk jom Enc . /� I APPLICATION TO FILE..LATE CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA BOARD ACTION Application to File Late Claim- ) NOTICE TO APPLICANT February 7.8 , 1989 Against the County, Routing ) The copy of this document mailed to you is your Endorsements, and Board Action.) notice of the action taken on your application by (All Section References are to the Board of Supervisors (Paragraph III, below), California Government Code.) ) given pursuant to Government Code Sections 911.8 and 915.4. Please note the "WARNING^ below. Claimant: SUSAN W, BUSBY County Ccuntzc c/o Law Office of Maryanne Britten Attorney: Salvio Pacheco Square J A I q 2 i 19EQ' 2151 Salvio St . -4399 Martinez, CF}, 94,553Address: Concord, CA 94520 Amount: $2', 920:00 By delivery to Clerk on January 23 , 1989 hand del . Date Received: January 23 , 1989 By wail, postmarked on no envelope I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above noted Application Lt File Late Claim. DATED: January 27 , 1989 PHIL BATCHELOR, Clerk, By Deputy II. FROM: County Counsel T0: Clerk of the Board of Supervisors { ) The Board should grant this Application to File Late Claim (Section 911.6). ( ✓ The Board-should deny this Application to File Late C m tion 1.6). DATED: �27 ' VICTOR WESTMAN, County Counsel, Deputy III. BOARD ORDER By unanimous vote of Supervisors present (Check one only) ( This Application is granted (Section 911.6). ( ) This Application to File Late Claim is denied (Section 911.6). I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. DATE: FEB 2 8 1989 PHIL BATCHELOR, Clerk, By �� Deputy WARNING (Gov. Code 5911.8) If you wish to file a court action on this matter, you must first petition the appropriate court for an order relieving you from the provisions of Goverment Code Section 945.4 (claims presentation requirement). See Government Code Section 946.6. Such petition must be filed with the court within six (6) months from the date your application for leave to present a late claim was denied. You may seek the advise of any attorney of your choice in connection with this matter. If you want to consult an attorney, should do so immediately. IV. FROM: Clerk of the Board T0: 1 County Counsel 2 County Administrator Attached are copies of the above Application. We notifed the applicant of the Boards action on this Application by mailing a copy of .this document, and a memo thereof has ben filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. MAR 2 1989 DATED: PHIL BATCHELOR, Clerk, Deputy By , 1 LAW OFFICE OF MAWANNE BRITTEN Salvio Pacheco Square � 2 2151' Salvio Street, Suite #399 Concord, California 94520 REE 9' 3 Telephone (415) 825-9448 I JAN 2 3 1989;� ; 1 4 Attorney for Claimant SUSAN W. BUSBY P B HEtoR 5 F k SO^S N T i BY - tv 6 7 8 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY g Re: Claim by ) APPLICATION FOR LEAVE TO PRESENT LATE CLAIM 10 SUSAN W. BUSBY ) 11 Against the County of Contra Costa ) 12 I, SUSAN W. BUSBY, declare and state and if called as a witness would 13 testify as follows: 14 I am the Claimant in the above-referenced matter. 15 In April of 1988 I presented Marshal Roger Davis with a Claim for 16 retroactive pay. At the time I was not represented by counsel, although I was 17 aware of Government Code Section 911.2. I felt that giving notice to the head 18 of the department within the County of Contra Costa was sufficient notice for 19 purposes of Section 911.2. 20 Further, the cause of action in this matter did not arise until July 21 26, 1988, the date on which the Director of Personnel denied my claim for 22 retroactive pay. A copy of said memorandum is attached hereto as Exhibit "A" 23 i and by this reference made a part hereof. 24 Based on the fact that the cause of action did not arise until July 25 26, 1988, the Claim filed with the County of Contra Costa on December 16, 1988 26 is timely under both the six month statute and the one year statute. 27 In addition, the Claim filed on December 16, 1988 relates to a cause 28 I of action other than for death or injury to person or personal property or 2 growing crops. The one year statute of limitations therefore applies. 3 Assuming, arguendo, that the Board finds that Claimant did not file a 4 timely claim, Claimant asserts that her failure to present the Claim was 5 through mistake and excusable neglect in that she felt her notice given to the 6 head of her department was sufficient notice pursuant to Section 911.2. 7 Claimant further asserts that the failure to present the Claim within the time 8 specified in Section 911.2 did in no way prejudice the County of Contra Costa 9 in its defense of the Claim. 10 I declare under penalty of perjury under the laws of the State of 11 Calfornia that the foregoing is true and correct and was executed in Concord, 12 California on January; 1988. 13 14 zzx) USAN W. BUSBY 15 16 17 18 19 20 21 22 23 24 25 26 27 28 t Contra Personnel Department Costa Administration Bldg. 651 County Pine Street Martinez, California 94553-1282 fir(:r'.�'��E.D 0!11. 2 9 Ma ,. tG�n July 26, 1988 TO: Rodger Davis, Marshal FROM: Harry D. Cisterman, Director of Personnel BY: Richard K. Heyne, Supervising Personnel Analyst SUBJECT: Peace Officer Career Incentive Allowance regarding Susan W. Busby Emp.#37169 This is in response to your memorandum dated 6/21/88 regarding Peace Officer Career Incentive Allowance, for Deputy Marshal Susan W. Busby Emp.#37169. I must advise you that the Personnel Department has no authority to recommend retroactive POST Career Incentive pay for an employee other than from the 1st of the month following issuance of a POST Intermediate Certificate, which in this case would be May 1, 1988. By copy of this memorandum I will advise the Auditor-Controller to initiate retroactive career incentive Allowance for Deputy Susan W. Busby effective on May 1, 1988. MR/RKH/amc o � CEOVED FILED A U G 3 1988 AU G ;31988 i MUCOUNTY COURT CONTRCALIFORNIA'rA MT.DIABLO JUDICIAL DISTRICT MARILYN IL tiCK.CLERK BY DEPUTY CLERK Claim to: BOARD tar SUPERVISORS OF CONTRA COSTA MuM INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 19879 must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person . or to personal property or growing crops and which accrue on or after. January .l, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the oause of action. (Govt. Code 1911.2.) H.. Claims must be filed with the Clerk of the Board of Supervisors at its offloe In Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553•' C. If claim is against. a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate Claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. sws +rssra • �rrrw • �t +. • rs • +r • • sss • +r �r # arrr0 .0a0 • .• * re RE: Claim By ) Reserved for Clerk's filing stamp SUSAN W. BUSBY 4+.,�.Vl , AgaInst the County of Contra osta ) W ) i j District) Fi 1 in name ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of 2 , 920.00 and in support of this claim represents as follows: �---N-N-----�---MN-NM--N--NNN- --N--N-N-MN-N-N ' 1. When did the damage or injury occur? (Give exact date and hour) From January 1985 until July 2.6, 1988 N--------------------- -N-NNN-NN-N-NN----------NNN-�-�� .. 2. Where did the damage or Injury ocour? (Include city and county) City of Concord , County of. Contra Costa •. ��-NNN--N------�-----------N-N-NM---NNN-N-NNNN----N------N--NNS ' 3. How did the damage or injury occur? (Give full detailsf use extra paper if required) Claimant became eligible for her Intermediate POST Certificate in January 1985. Claimant was not provided with any guidelines by her employer, .. Contra Costa County Marshal ' s Office. Claimant later discovered that q�ne ugee of--her srior officer ' s had instructed that deputies not be told that they. w were �. 4. What particular act or omission on the part of county or district officerg, .eligible. servants or employees caused the injury or damage? The act /omission on the part of claimant ' s superior officers in not advising claimant that she was eligible for her Intermediate POST Cert *fi- cate and in fact suppressing said information. i (over) •GUTJ PUB '4sTadmT qmg tnoq Aq ao 9000101$) sagTTop puesnog-4 usl BuTpaaoxe 4ou jo euTj s Aq 'uoulad egw4s eqg uT quswuosTadmT Aq ao 'auTj pue guamuosTadmT gana gaoq Aq ao '(000`T$) puesnog,4 auo BuTpaaoxe 4ou jo auTj s Aq 'asaA auo uEgP aaom 4OU JO POTaad s aoj TTOP Aqunoo aq,4 uT 4uewucmTadmT Aq aaggTe atgsgsTund sT 'BuTgTaM ao 'aagonon ',4unoo0s 'TTTq 'MTBTO guaTnpnsaj ao asTej Aug 'auTnuaB jT awes aqq AEd ao MOT-118 o14 pazjaoygne 'aaoTjjo ao Pnq 401449TP ao A110 'Agunoo Aus o1 ao 'aaoTjjo ao pagoq a,4egs Aug of quamAsd aoj ao aousmoTTo aoj sguasaad 'pnwjap o1 quaquT ggTM 'oW uosaad AaaAa„ :sapTnoid spo0 teued 8tn jo EL uoTpog 3 3 1 1 0 N # a # a a a a a a Ll a a a a a 0 # # # # # # # a a a * a a a a a a a # # # #. 0 # # •ON auogdalaZ 8 b b 6-S Z 8 •oN euogde Eo j, .Gb6 VD ' p,aoouo0 ' anT-TQ pooMwng OUT goeappy) OZSb6 KO ' PIoauo0 .».. ..., gsng •M uesns 66£ a3TnS ' gaaagS OTATVS TS-[•Z • (�gs9TS �l�TgtO) aaenbS ooagoed oTnTeg 3i„ ias 3NNKASVN 30 3OI330 MK'I u';;rig MMV&VW Aauaoggy jo gsaippv.ptm amep u•jle4eq sTq uo uosied smog hq ao ( ouaolly) :01 SMIJON am gUVWTVTO 044 Aq PaUBTs Qq Ism mTgTO Mull seepTnoad Z•O16 •oaS aPOO •AO`J auou ' MUM MLI &Lva :A=NT ao guapToog sTq,4 jo qun000E uo apsm noA sa mgjpuadxa aql IST'I 06 -----_---N__N------_______NNNNNN____N__N__W___N_.. ( 33TjagS Agndaa Mou) Tegs.zeN Agndea ' EgsoO anagS (uTeldeo 33TjagS Mou) TegSJeW ' sTnea JaBOH •elw4ldsoq pus saogoop 'sassaulTM jo sassaappE pub samsN •g -_N_N__--N_-M__NN___-M___NAN_-NN---------------------NNN--------_--__w_ p8T4T4ua SEM aq8 gDTgM 04 anTaDaa qou Pip quewreTo q,4uow xad 00 '£L$ sawT-4 sgquoui 0i, (•alumep ao AanpuT GANoedsoad Aum jo qunome paquml,4sa eqq apnTouj) Lpa-4ndmoo anoqu pamTETo Wnome aqg sEM MOH 'L _---- 00 '0Z6 'Z$ : sagewep Tegoy • s.zeaA 3Teq-auo pue aajgj 3o poT.zad a 109 u0T4eaTJT4aao ZSOd ageTpaWJaqul paivap seM 4uewTeT3 •82amep olne aoj s9gvmTgs9 oMq gogjgy •pemllop saftmsp ao saTanCUT jo guagxa TVU aATO) LPsglnsaa mTBTo noA op saTan�uT ao 92umvp jeu 'g �y--_----_•_-__--_N_NWNN_NN_---___-_N-NNNN__N Mr�M ZeAego dTTTTgd LA=PUT ao GOMM agg BuTenso saaAOTdme ao squgnaas 'saaoTjjo 10Ta1sTp ao AV= jo SOMOU aqg aas 174A •y CLAIM //5 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT February ?8 , 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: Unspecified Section 913 and 915.4. Please note all " rnin " 16o un` Y'Counsaf CLAIMANT: GLENN GRAY 1309 Markham FEB 011989 ATTORNEY: Modesto, CA 95351 Date received Martinez, GA 94553 ADDRESS: BY DELIVERY TO CLERK ON January 31 , 1989 Risk Mana . BY MAIL POSTMARKED: January 28 , 1989 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. Januar 31 19.89 HHIL BATCHELOR, Clerk DATED: Y BPpY: Deputy L. Hall II. FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: 17 Dated: rJ`` ' I — V ! BY: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. p� o Dated: FEB 2 8 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: MAR 1989 BY: PHIL BATCHELOR by puty Clerk CC: County Counsel County Administrator Claim t BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person . or •to 'personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than 'six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of. the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street; Martinez, 'CA�94553• C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code ec. 2 at the end of this form. - RE: Claim By ) rk Against the County of Contra Costa or ) EB RS. District) pN R A'F. Fill in name ) °L Rx By The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ and in support of this claim represents as follows: ' ------------------------------------------------------------------------------------- 1. When did the damage or :injury occur? (Give exact date and hour) 13 -- x- . 3 % ------------------------------------------------------------------------------------ 2. Where did the damage or injury occur? (Include city and county) o�11QR ------------------------------------------------------------------------------------ 3. How did the damage or injury occur? (Give full details; use extra paper if required) KL( CqNp, w fiS I-kZT pe-61M -t-4E EIA (P Ts'IO P res s;r�RT—%zD . To C.RaSS TtiC s o __TNEL CAR, = . .lei 1 OF MC --------------------------------------------6 What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? (-., � (over) 5. What are the names of county or district officers, servants or emplo'7ee sing the damage or injury? J p S Cf'l~} d AaC H A R L ---------------------------------------------------- What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates'for auto damage. fXC#- JZR�R(2 Coktj k . 4k t-v PAZTS 1-r;-z S ©I4 E S TFs ------------------------------------------------------------------------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Co�AW-VEO O-Z e p*`2 5 4d) -�� z e-t'A PAs. O'D 14E. To J%Y cA R. ------------------------------------------------------------------------------------- 8. Names and addresses of witnesses, doctors and hospitals. ------------------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT V SAO VN7k--15- Zjb t4 E 07q 6WT4 1 Wt Gov. Code Sec. 910:2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf." Name and Address, of_Attorney Claimant Signature (Address) CA Telephone No. Telephone No.C20g2 NOTICE Section 72 of the Penal Code provides: "Every person, .who, with intent to defraud, presents for allows,qt T for payment to `any state board or officer, or to'any county, city or 'distri C' officer, authorized to allow or pay, the same.if genuine, any false or claim, bill, account, voucher, or writing, is punishable either by iWAVj nt in the county jail for a period of not more than one year, by a fine�,,of not Me4 . one thousand ($1,000), or by both such imprisonment and fine, orifi,imprisonment in the state prison; by a fine of not exceeding ten thousand dollars (�lb,�'© fin both such imprisonment and fine. 37?415) Rvd.' GOLDEN STATE AUTO BODY Ne94560 BODY & FENDER REPAIRS ESTIMATE OF REPAIRS Phone91-7107 CUSTOM PAINTING & BODY WORK 1- INSURANCE REPAIRS —FIBERGLASS REPAIRS Owner: �'+�_ t� Address: C? �/ � Date: Year: Make. Model: License#: -_2_S V.LN.: Mileage: Color: 1�1 (Ir S//-k-'d : zy Contra Costa County RECEIVED JAN 31 199 Risk �Aanagement • ®EMO= TT ® ® Ftle Mill �M�� =11111111 ��!M PARTS PRICES SUBJECT TO MANUFACTURER'S INVOICE 1 t R Contra Cost, VlEb county 'IAN 3 z 1989 Risk - A4, 1989, nv, r � ` At ° T 6 63 � � ��' ,� '�,2 dj m 4s N iso L VA JO is ot. v M '� CLAIM 1. 1 ' BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT February 2<.8 , 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: 'N3175 . 0 0 Section 913 and 915.4. Please note all MA1 0Csouns CLAIMANT: Y:AREN ZIEMANN 3917 Gentrytown Drive FEB 011989 ATTORNEY: Antioch, CA 94509 Date received Martinez, GA 34553 ADDRESS: BY DELIVERY TO CLERK ON January 31 ," 1989 hand del . BY MAIL POSTMARKED: no envelope I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. �bIL gATCHELOR, Clerk DATED: January 31 , 1989 : Deputy L. Nall II. FROM: County Counsel TO: Clerk of the Board of Supervisors (�/) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: U BY: L Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( ) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date.. yry 1;�� Dated:—FEB 2 8 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov, code section 913) Subject to certain exceptions, you .have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: MAR 2 1989 BY: PHIL BATCHELOR by Clerk CC: County Counsel County Administrator Claim to,: -"'" BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must. be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must jbe presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action mustbe presented not later than !one year after the accrual of the cause of action._ (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553• C. If claim is against a district governed by the Board of Supervisors, rather than. the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. ,. # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #. # # #:#;•�E # # # RE: Claim By ) Resery d TP ) IV Against the County of Contra Costa ) JAN 3 11989 or ) 3 : 3 6- P-rl PH!L BATCHELOR -District) CLERK BOARD OF ST PERVISORC Fill in name ) s & �:. � S.:Deputy The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ and in support of 'this claim represents as follows: ------------------------------------------------------------------------------------- 1. When did the damage or injury occur?- (Give exact- date and--hour)_—____ _ _ --------�'� !- -------- =rO.�"------------------------------------------ 2. Where did the damage or injury occur? (Include city and county) 3. How did the damage or injury occur? (Give full details; use extr paper if required) ( 4. What particular act or omission'on the part of county or district officers, servants or employees caused the injury or damage? �✓A° (over) 5. What are the names of county or district officers, servants or employees caasing' the damage or injury? ----------- --------- ------------------------- 6. What damage or injuries do you claim resulted? (Give full extent of injuries or- damages claimed. Attach/ttwd estimates for auto damage. -------- ------------------ ------------ } 7. How was the amount claimed above computed? (Include the estimated amount-,of any prospective injury or damage.) 8. Names and addresses of witnesses; doctors and hospitals. ---=--�'� --nesy - '------------- � ------ - '-_-----_------- 9. List the expenditde on account of this accident or injury: DATE ITEM AMOUNT IF It It IF it It It IF IF It Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES T.O:: ;.(Att'orne )... or by some person on his behalf." Name and Address of;Attorney. Cl is Signature Addre Telephone No. - I.--Telephone -No: / `"�o-f __ .•_:�r___�.__,,:»- NOTICE Section 72 of the Penal Codeprovides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in. the county jail for a.period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. To From Our File Your File Subject Date f9 — i` � Signed � �v�.�' An immediate reply will help finalize thils-mager. Date 19 Reply Signed GO-144-C(OS-7-75) Printed in U.S.A. To From Our File Your File Subject # Date 19 — 4.9 y An immediate reply will help finalize this ma-der/ Reply1/.J f Y '.; i"r,<.� Date 19 Y Signed Printed in U.S.A. GO-144-C(OS-7-75) _ � _ � - 4 .. C To From Our File Your File Subject _ �. Date 19 — r An immediate reply will help finalize this mafter/ Reply Date 19 h A Signed Printed in U.S.A. GO-144-C(OS-7-75) REOUISITION ON (PARTS ROOM DATE OWNER Y '/�� REPAIR ORDER NO. MAKE OF CAR " I' A 2181 MODEL CITY. PART NO. ARTICLE PRICE AMOUNT 6 l - / -7-//f7- Cc/�N!JSHI ' 7 75 — Y� r�y,ru,, r, . TOTAL ORDERED BY O, K. FOREMAN FORM 27 NORICK BROS..INC..OKLAHOMA CITY DAN'S CONTRA COSTA GLASS MOBILE GLASS SER VICE Specializing in Auto Glass Residential& Commercial 1140 ERICKSON ROAD CONCORD, CA 94520 (415) 827-4173 DATE NAME ADDRESS _F,O.B. _. -INVOICE NO. _.. SOLD.BY.. ._ --❑ COD---.._.. ❑ CHARGE CITY - CUSTOMER'S ORDER NO. POLICY NUMBER INSURANCE AGENT PHONE ( 1 r f L YEAR&MAKE TYPE&MODEL SERIAL NO. SPEEDOMETER N0. LICENCE NO. i FURNISH FURNISHLABOR DATE PROMISED. TIME _ __ AUTHORIZED BY & INSTALL ONLY ONLY A M P.M. QUANTITY PART OR SIZE NO. DESCRIPTION LABOR I I 1 I I I I SALVAGE ESTIMATE $ TOTAL 1 PARTS I DELIVER TO ❑ WILL CALL TOTAL LABOR I JOB NAME ❑ DELIVERY TAX 1 ADDRESS MAP # TOTAL CITY Fj -'- 1 HOME PHONE ( 1 WORK PHONE 1 1 To ' 'Date Hour While you were out... Name of Phone No. =telephoned =will call again called to see you =please phone=returned your call=please see me Message Signed Printed in U.S.A. GO-24(OS-6-84) routing Slip-G10:24 To =Immediate Attention=Prepare Reply =Return =Approve =For Signature Q Route =Comment =See Me =Trace =Handle =Destroy =File =Note =Hold Remarks From Date Printed in U.S.A. GO-24(OS-6-84) J 733-7yC;l -- - =. ., ... /ff y CLAIM �yyJ BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA ' ali__;,(Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT February 28 , 19:39 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $20, 060 . 30 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: MARY JANE CUIDIINGS County Counsel 1485 Waller Street #107 JAN 2 Y 1989 ATTORNEY: San Francisco, CA 94117 Date received Martinez /� 94553 ADDRESS: BY DELIVERY TO CLERK ON January 2.7 , 1989 and el , BY MAIL POSTMARKED: no envelope I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: January 27 , 1989 PpHHIL gAATCHELOR, Clerk BY: D putt' L, Hall .11. FRD�M• County Counsel TO: Clerk of the Board of Supervisors (✓ ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not .timely filed. The Clerk should return claim on grouod that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: – C BY Deputy County Counsel IV III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (x) This Claim is rejected in full. (rr \\) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated:— FEB 2 8 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: MAR 2 1989 BY: PHIL BATCHELOR by y Clerk CC: County Counsel County Administrator f +CLAIM AGAIIIS'f: CONTRA COSTA COUNTY and CONTRA COSTA COUNTY SHERIFffS DEPARTMENT Mary Jane Cummings hereby presents a claim for damages against CONTRA COSTA- COUNTY and CONTRA COSTA COUNTY SHERIFFS DEPARTMENT CLARIAEJV S AD1)11 SS IS : 1485 Waller Street, #107 - San Francisco, CA 94117 C.l.nIni tttt desires tit.-It all Notices or other_ commutticatlotts with regard to title claim be seat to : 1485 Waller Street, #107 - San Francisco, CA 94117 DA'Z'E OF OCCU1UW-1JCE: July 29, 1988 PLACE OF OCCU1Llt1;HCE: Concord Naval Weapons Station • Concord, .Ca ifornia SAID CLAIII ARlSLS OU OF '1110 1-ULLUWI11G CIR0U11S'YA110ES : I was falsely arrested at Concord Naval Weapons Station. told to sit in a chair for 12 hours and was not dilowed to- walk Or lie down. My baek beeaffle severely aggravated. This caused me lost wages, suffe4n and-pasn. \QN2 � 0 S�pE• ��r� Wit: � ��fP ,-- •;i, 11MIE A11D CAI'ACUY OF Enrl.UxEES UC Unknown A11011T CLA11iE1): SPECIAL DAHAGCS •1'U DATE: $ $60.30 Lost wages (5 hrs @ $12.06) GEtJE1tAL DAUTAGES -•1'U� DA'Z'E: $- 51000.00 Pain, suffering embarrassment, anxiety, defamation o character, ES'f itlA'1'ED FUTURE DAVAGES : - a% change i n persona i ty $15;000.00 Embarrassment & loss of potential --- due to report on future applications; ES'filIATED TOTAL TO DA'Z'E: $20,060.30 change in personality I declare under penalty of perjury that the above is true and correcL.. Executed at San Francisco , California ott: Thursday, January 26, 1989 / CLAIM / BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA r. Cl-ti,r Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT F els ruary28 , 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $2, 500 . 00 Section 913 and 915.4. Please note all "Warr,JMhty COunsel CLAIMANT: ROBERT LOUIS NELLEN JAN 2 f X9$9 2824 lay -Rodd ATTORNEY: E1 Sobrante , CA 94893 Martinez, CA 94,553 Date received ADDRESS: BY DELIVERY TO CLERK ON January 2.7 , 1989 hand del . BY MAIL POSTMARKED: no envelope I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. January 27 , 1989 PpHHIL BATCHELOR, ClerkSe2L DATED: BY: Deputy L, Hall II. FROM- County Counsel TO: Clerk of the Board of Supervisors (✓ ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: Z L " O BY Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (x) This Claim is rejected in full . ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. 9 Dated: FEB 2 8 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you .should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: MAR 2 1989 BY: PHIL BATCHELOR by putt' Clerk CC: County Counsel County Administrator i Clariin to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY " INSTRUCTIONS TO CLAIMANT •A. Claims relating to causes of action for death or .for injury to person or to per- ) sonal property 'or growing crops and which accrue on .or• before December 31, 19879 must be presented not later than the 100th day after the -accrual of the cause of action. Claims relating to causes of action for death or for injury,to.:person - . . . . or to 'personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of-the cause of action. (Govt. Code. §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room'106, County Administration'Building, 651 Pine Street, Martinez, CA 94553• C. If"61aim is "agafnst a district- governed by the Board'•of Supervisors, rather -than, the 'County, the name of the-District should be filledin :!! D. If the claim is against more than one public entity, separate claims must be filed against each public entity. L E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end. of this form. * e * e * � e e * ee * e * ee RE: Claim By ) Reser ed o e ' f' ing stamp Robert Louis Nellen ) Against the County'of Contra' 'Costa' ) ( or ) .,�a ri 2'7'1989 rp� District) P L A CHELOR CL ^K Cf A E R^ISOF1J Fill in name ) 0. - 4% •�• -—OPnutV The undersigned claimant hereby. makes claim against the County of Contra Costa or the above-named District .in the semi of $2,500. and in support .of this claim represents as follows: ------------------------------------------------ --- - ----- 1. When did the damage or injury occur? (Give exact date and hour) A tree fell down and ripped the electricity from a house I .rent; Dec. 23, 188 at 8:12 am ------------------------------------------------------------------------------------ 2. Where did the damage or injury occur? (Include city and county) On the creek behind the house at 2824 May Road, E1 Sobrante, Contra Costa County, California ------------------------------------------------------------------------------------ 3. How did the damage or injury occur? (Give full details; use extra paper if required) After a week of wind & then rain storms, a huge dead tree snag blew down onto the PGE line just behind my house & ripped the wiring off my house. I was without electricity for one month, ------------------------------------------------------------------------------------ 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage?I had notified Mr. David. Reesa of the Contra Costa County Flood control twice that the dead tree was in danger of falling down & knocking out my electricity. He said they wouldn't do anything until the tree fell. When the tree fell he still wouldn't do anything. He didn't tell me the Flood Control wouldn't fix the Wiring if the tree fell; he didn't note to me that the tree was on a neighbor's property and not on ours; and, he didn't notify my landlord or the neighbor in writing of a flood control hazard. Mr Reesa apparently was new to his joQbl@A)I don't thinly I should suffer for one whole month without electricity because of his lack of experience. 1, I have lived there for 12 years and Mr. Ira Waldron--the flood control officer pre0-tviing Ravi Reesa waettaWsM there orecedemmof taking very good care of us & cutting Mood & debrr33n from a pro 5c-re6t are the names of county or district officers, servants or employees causing the damage or injury? Ira Waldron set up my expectations; David Reesa was not clear (¬hing in writing to anybody)--in fact I called him immediately after the tree fell down_ and expected him to fix the electricity; and, Jim Causey because he didn't make it clear that it wasn't a flood control right-of-way and their job to maintain as_.I_had been lead tb -befe'vw.-'7tig�- ;1!'1CpiSf';-6dch�i°�e Re-sa 3'F�.-"C•on o1 ii�-u�reK, Biu pr .Vc6. What damage or injuries do you c aim res ted (Kive en !org damages claimed. Attach two estimates for auto damage. This happened over the Christmas Holiday & I stayed at my parent's & sons house, ------------------------------------------------------------------------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.), spent about $100 for propane. I had the charity of my families hospitality. I spent a lot of money eating out & entertaining myself out of my home. It was too dark & isolate to sit in a dark house in the middle of acres without television or lights, It ,O y not be accountable in $ but I feel my discomfort should be -gatd'-fun ---------------= ---------------------------------------------------------- 8. Names and addresses of witnesses, doctors and hospitals. Mr. & Mrs. Cappizi; Joe Rubino; David Gray; Bertha Nellen: various PGE employees; Cornish electrical; Mr Ugene Martinez; Roy Kindrick, et al. I can furnish addresses if requested. ------------------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT Propane:almost every other day--that should be almost a hundred dollars. The rest is hard to measure; I lust survived & should be raid for the Foodoto ' , Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: '(Attorney) or by, s e on his lf." Name and Address of Attorney i C ai t Signature) Addres Telephone No. Telephone No. 415-222-3072 * * * * * * * * * * * * * * * ViF '�F NOTICE - . Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment .to.any state board or officer, or to any county, city or ,district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail -for a period of not more than one year, by a fine of not exceeding one thousand ($1,000),. or by both such imprisonment and.,fine, or, by imprisonment in the -state prison,. by a fine of not exceeding ,ten .thousand dollars ($10;000, or" by both ,such imprisonment .and fine.. . CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT February 23 , 1939 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes., ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $246 . 0 0 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: NANCY E, DURHOLZ County Counsel P. O. Box 501 ATTORNEY: Orinda, CA 94563 JAN 2 7 19$9 Date received ADDRESS: BY DELIVERY TO CLERK ON January ? iarh CA 94553 BY MAIL POSTMARKED: January 25 , 1989 I. FROM: Clerk of the Board of Supervisors TO: County Counsel_ Attached is a copy of the above-noted claim. DATED: January 27, 1939 EYIL ELOR, Clerk BgATCH; Deputy L, Hall II. FROM- County Counsel TO: Clerk of the Board of Supervisors (V ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: BY Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (X) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. FEB 2 8198 Dated: PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: MAR 2 1989 BY: PHIL BATCHELOR by uty Clerk CC: County Counsel' County Administrator I Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine.Street, Martinez, CA 94553• C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate -claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By ) Reserved for C erk's filing stamp Nancy E. Durholz ) I ) 171 ( _Tl` 7�P Against the County of Contra Costa ) or ) J A N 2 61989 District) Fill in name ) "LO COD: a The undersigned claimant hereby makes claim against the County of Contra Cos a or the above-named District in the sum of $ 246.00 and in support of this claim represents as follows: ------------------------------------------------------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) October 26, 1988 - 5:05 PM ------------------------------------------------------------------------------------ 2. Where did the damage or injury occur? (Include city and county) Orinda Public Library, Orinda, CA. Contra Costa County ------------------------------------------------------------------------------------ 3. How did the damage or injury occur? (Give full details; use extra paper if required) See Attached ------------------------------------------------------------------------------------ 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? Failure to adjust both doors for equal rates of closing so that patrons are unable to anticipate both doors operating in same way the way they now are. (over) t 5. What are the names of county or district officers, servants or employees causing the damage or injury? Contra Costa County personnel - names unknown - responsible for proper operation of doors in question. -------------------------- --------------------------------------------------- 6. What damage or injuries do you claim resulted? (Give full extent of injuries .or damages claimed. Attach two estimates for auto damage. $240.00 , treatment for contusion of left elbow and upper arm. . ------------------------------------------------------------------------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Invoice from UC MED emergency room service - copy enclosed/attached. ------------------------------------------------------------------------------------- $. Names and addresses of witnesses, doctors and hospitals. Priscilla Daffer; 129 Overbill Rd; Orinda, -CA. 94563 UC MED Fhmergency room personnel. San Francisco, CA. ------------------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT 10/27/88 UC MED $240.00 Prospective as yet undetyrmined. Gov. Code Sec. 910:2 provides:. "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) grby orbsome person on his behalf." Name and Address of Attorney �q. C Claimant's Signatur Address 6-9 Telephone No. Telephone No. c,?-T4 NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine -of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by' both such imprisonment and fine. i I was leaving the library with five books I had just checked out and which I held (as usual) in my left arm. The door on right was occupied by persons (one of whom was handicapped) thus causing me to use the left door. I pushed the cross bar with my right hand, opening it far enough 'for what should have been ample clearance for me to walk through it without incident. (This judgement was based upon the closing speed of the right door, through which I have exited dozens of other times with no problem) . As I passed through the open door, it snapped shut at a faster rate than it should have, thereby striking my left elbow and .upper .arm. Nancy"E E. Durhol z I eVU I FAI lhNl STATEMENT UG '• " The Medirat Center at the University of California;Sart Francisco .,! DURHOLZ NANCY E E S 09016295-8301 10/27/88 TO 11/06/88 11/06/88 4;. . - •• a ••• o- • . • ix THE MEDICAL CENTER AT UCSF NANCY E DURHOLZ C/O FIRST INTERSTATE BANK OF CA. PO BOX 501 P.O. BOX 39157 « ORINDA CA 94563 SAN FRANCISCO, CA 94139 - 9157 — — PLEASE COMPLETE - i5 I CHARGE INFORMATION VISA,MASTERCARD AND 246 .00 AMERICAN�xPREss nccr_PTED ON REVERSE SIDE7746 .0 *-DETACH HERE PLEASE RETURN TOP.PORTION ONLY. DE)NOT ENCLOSE INQUIRIES IES'.-WITH YOUR PAYMENT. DETACH HERE. • _. ;TAX ID 9460364t93W .�'iE✓I DURHOLZ NANCY E J09016295-8301 TRANSACTIONS R'O O�RN TSTA STATEMENT _11/06/88 1.,_. • e • s 0. • P i,. 10/27/88 47401001 EMERG .VISIT• I-I . .ti. 90510 131 .00 x,; 10/27/88 39300169 ELBOW HOSP FEE 73070227 80.00 10/2,7/$8. 39300169 ELBOW PRO::. FEE 73070226 35.00 r S41GKIl ... ... .. .-. �`+'t't�Yy >"'..�� �.'' 't J � .;S 4ie h•++�; ... a-. .. I.. ,r BUSINESS OFFICE HOURS:9:00 AM - 4:00 PM MON - FRI ACCOUNT BALANCE IF YOU HAVE ANY QUESTIONS CONCERNING THIS STATEMENT,PLEASE CONTACT:(415)476-6876 _,, LAST STATEMENT 0 . 00 NEW CHARGES/ PATIENT SERVICES UNIT PHONE: 415-476-6876 ® 2,46.00 }, ADJUSTMENTS NEW PAYMENTS/ CREDITS ® .0. 00 CURRENT 246. 00 F4 a by t i; s ACCOUNT BALANCE 'kali t }`kK kp 1, AMOUNT BILLED TO INSURANCE 0. 00 l k t A f t !n PLEASE PAY THE BALANCE DUE UPON RECEIPT OF THIS STATEMENT. 246. 00 o I SEE REVERSE SIDE FOR e o PATIENT FINANCIAL INFORMATION a CD CO 1 Ci in 7. /--0�74� N-I V�l Q r CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA 4 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT February 28 , 1959 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $134. 99 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: CAROL ANN HARRISON County Counscl 2424 Elgin Lane FEB 01 1989 ATTORNEY: Walnut Creek, CA 94598 Date received ��Afl� 94553 ADDRESS: BY DELIVERY TO CLERK ON Januar AA y � ani. del . BY MAIL POSTMARKED: n0 envel I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: January 31, 1939 gyIL BATTCYELOR, Clerk epu L. Hall II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( V) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: o�-' l — O BY: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present This Claim is .rejected in full. ( ) Other: I certify that this is a true and correct copy.of the Board's Order entered in its minutes for this date. 00 FEB 2 8 1989 Dated: PHIL BATCHELOR, Clerk, BDeputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: MAR 2� 1989 BY: PHIL BATCHELOR b _WZK____y Clerk CC: County Counsel County Administrator . laiv � BOARD. OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for..death or for injury .to person or. to per- sonal property.or growing crops and which accrue on or before .December 31, 1987, mustbe presented not later thari'the 100th day after- the; accrual of .the cause of. action. . Claimsrelating to causes of action for death or for injury to person or .to.,personal property or growing .crops and.which accrue ,on .or, after January 1�,- 1988, .must, be presented not later than six- months after; the accrual of: the cause, . of. action. Claims relating to. any other. e'ause. of action must, be presented. not , later than one year after the accrual of the cause .of action. ' (Govt. .Code .1911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553• C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the. claim is against more than one public entity, separate claims must be filed against eaci ,public entity,,. E. Fraud. See penalty for fraudulent claims, Penal_ Code Sec. 72 at the end of this form. N RE: Claim By ) Resery d C k amp,: Against the County of Contra Costa ). N 8 District) CLERI p' rc LOR UPERVISORS Fill in name ) ay .. .R i The undersigned; claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ 13� ,q q and in support of this claim represents as follows: ------------ ----------------------------------------------------- 1. When did the damage or injury occur?-- (Give exact date and-hour)- ------------- - -------------------------------------------------------------- 2. our)------------------------------------------------------------------------------------- 2. Where did the damage or injury occur? (Include city and .eounty) Sk iris `F----------- 3. How did the damage or injury occur? (Give full details; use extra paper if required) r, num r ------------------------------------------------------------------------------------ . 4. What- particular act or omission.on the part of county or district officers, servants. or employees caused -the injury or damage? (over) { 5. What are the names of county or district officers, servants or employees eamOng l the damage or injury? �. C,l kl� �`F�Q� ���aL i�.�v,�� 1�c c��,.1- s�,� s.o�a�k � v�"f 4.:S r,v,��s t.�i.C�a�•• --------------------------------------------------------------------------=----0----- 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages Q claimed.. Attach two es.timates for auto damage. g w - - ) -,cR� � B,� isI w1.n ti ►eA .,�a r �C�a s�nf) Sh.�-toJ.s 3Z4s k�o-.o �cM3 a44$ �'w.ts 93.89 ---------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) r�J'a`lV-.C, o.o�.c�i�'�.1y� � C.Q0.�.w.. rv�Ar�a, `F-.Y� yv..c•..iw��Q, ps'_ '�`` ---------------------------------------------- =��===�= -- v _ ---- 8. Names and addresses of witnesses, doctors and hospitals. r Le-,,, 0.- - wK� ttt5h'1 -7 �c����:secs u.wY-- (q PS (0 E4 7 i 11-\4-e_vrl0„:3 o---- crCC� c�9—rel- �'�G� ��k • L�-tis��e�n� --� )---- --r--�T --��4o-{-s.-a,F a;r- C k c E ---------�,-----5- 9. zist''�the e f 5` —ry: xpnditures you made on account o this accident or injury: DATE ITEM AMOUNT PNZk Ao Gov. Code Sec. 910:2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf.” Name and Address ,Of;Attorney . (Claimant's Signature (Address) S4 }� Telephone No. Telephone No. �I s 7 L/ – N O T I C E Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board' or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one -thousand ($1,000), or by'both such imprisonment and fine, or by imprisonment in the state prison, by 'a fine of not exceeding ten thousand dollars ($10,000, or by both such-'imprisonment and fine. 4 t J . t cA., b �- 1 F=-�r`�s.... Cr-C•C.,�.c�.9�n.�,.'`�, �-�,,, vJ c.� �C`.Q.CAc�-�--v� o..r.�..30.�...� �3`� j Pte" '�..A-�sL. C3�.�..sZ C.�•...�-.�v�. C�� "�.�ca.., l-�C3.�n..._,r� �1�...�..�.. 1�j(�� �-�`(R..�..N��.-... ��. �..�,�..sL-s�... c._�ti.v�.��e�.�-•� T�r�,.�..`� �.�1..>,;, oma.C�rS-�"� �,.�.�.�. cesz,� �..-��-„-`� �.�,..,,� �-c A, �, �-moo.-� c�.s1..-�-,,x.57•- o�„ �-.,-.. CLAIM 'BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT February 28 , 1939 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $3, 343 , 76 Section 913 and 915.4. Please note all "Wa " e6uh4y Counsel CLAIMANT: LAURO BERNAL 406 North Buchanan Circle FE B 0 1 i°89 ATTORNEY: Pacheco , CA 94553 Date received Martinez, CA 94550 ADDRESS: BY DELIVERY TO CLERK ON January 30 , 1989 Risk Manag. r BY MAIL POSTMARKED: I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: January 31 , 1989 RAIL BAATputyLOR, Clerk L. Hall II. FROM: County Counsel TO: Clerk of the Board of Supervisors (1x This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: n. Dated: _ ( y 1 BY: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (�) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. � Dated: FEB 2 s 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. I AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: 'MAR 2 IJU3 BY: PHIL BATCHELOR by n@ptrfy Clerk CC: County Counsel County Administrator �ClaiBOARD_..'OF!SUPERVISORS'OF CONTRA COSTA' COUNTY , d INSTRUCTIONS TO CLAIMANT . rx A. Claims relating',to causes of action for death or for injury to person or .to per- nal property s d which accrue on or before December 1 1 8 so p • p y or growing crop an 3 , 9 7, must°'be"'Oresented-not later-•than••the 100th day after •the accrual- of the ,cause.-of•-- acti6h,,1.Claikb; relating- to causes •bf, action for 'death, or. for,rinjury to:person' or to personal property or>growing,-crops and which accrue 'on`. or 'after: January: l , ` 88 than six months after he accrual of the cause 19 , must be presented not later o t of action. Claims relating to any other cause of action crust be presented not `later than-"one''year 'after, the'•accrual of the cause- of -action. (Govt. -Code §911.2::) B. Claims must be filed with. the Clerk of the Board :of-Zupervisors 'at its'.' ffice' in Room 106; County Administration Building, 651 Pine Street, Martinez, CA 945530 i( C. If 'claim isagainst a district governed by the Board of Supervisors, rather than .-the-County;-the, name -of the District -should be filled in. ', - -- D�If--the-claim is against-more-than--one-public entity,separate-"claims must""be - - filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal. Code Sec. 72 at the end of this a ,. ...form. W..�,.,., ._......_.._._. .°.... ., ... .......... .._,_. ..._. ,. . .. . _ . ... ... w .. _ ...... � . RE: Claim By _ ) Rese v/,Z&x • ) ti 'E"; . IVED ' ''Against 'the'County of Contra Costa ) JAN 311989 or 7. PH r CLC-KB R �' cLOR c �j :. District), T �F • �E czs f Fill in name ) ey p r d The undersigned claimants reby'makes.claim against the County of Contra Costa or . the above-named District in the sum of. $ ` �, and in support of this claim..r_epresents„as follows: mill M1 1. . When did the damage or injury occur? (Give-exact date and.hour) ------. - �� :-- ----- -------------------------------------- 2. "Where did the` damage or`injury occur? (Include city and county) _ ,c----------------------- t: 3.' How did the damage or injury occur? (Give full details; use :extra� per .if required) fti'1�'b T. .T :)i� .4 r,._�I � r:i �.;j 7'ir l' ,. ., r . �y. ••• _;Yr _' S. 4. What`"parti'cular" act, or' omission on' the part of county 'or` district: officers; servants-,,ori'employees� caused'the injury or damage?-..., �4 r d�'�r a/T�,�®aU '�lI rt [/G�'�fv/'� J t. • , . ,j ' (over) JAS! 3 CT" L 4 / V Cry „ • U , V R C+ Q CLAIM Id. BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT February 23 , 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $2 , 000, 000 . 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: DEAN K. BUCKLEY County Counsel 883 Hartwick Avenue ATTORNEY: Turlock, CA 95380 JAN 2 7 1989 Date received M10WZ, CA 9 6553 ADDRESS: BY DELIVERY TO CLERK ON January 23 ,' BY MAIL POSTMARKED: January 17 , 1989 Certified P 157 989 751 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. January 27 1989 HHIL BATCHELOR, Clerk DATED: BPpY: Deputy L. Hall II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8): ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: ' 2� B Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (X ) This Claim is rejected in full . (��) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. p nnooQ Dated: FEB 2 8 1Jv J PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant asshown above. Dated: MAR 2 1999 BY: PHIL BATCHELOR by eputy Clerk CC: County Counsel County Administrator Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person .or to per- sonal property or growing crops and which accrue on or before December 31, 1987 ). must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or• to .per•sonnl property or growing crops and which accrue on or after January 1 , 1955, must, be presented not later than six months after the accr(.ral. of the cau.-r: of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911 .2. ; D. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building,. 651 Pine Street, Martinez, CA 9455'. C. If claim is against a district governed by the Board of Supervisors,. rather than the Ccunt.v, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims rmist b,-- filed efiled arainst. each public entity. Fraud . See penilt.y for fraudulent claims, Penal Code Sec. 72 at the end of this . f orr:i. RF.: Clain Reserved f C r 's ilin stamp Dean K. Buckley ) ) RECEIVED Aga i rat. j the County of Contra Costa ) or ) JAN 2 3 1989 J. R. Olsson, County Clerk CLE: ' P B 10AELOR ON .a' ps P C i l i in name The undersigned claimant hereby makes claim against the County of Contra Cost,:, or the above-nod District in the sum of $ 2.000.000.00 and in support of this claim represents as follows: -----------�-------------------------------------------------------------------------- 1 . When did the damage or injury occur? (Give exact date and hour) 9-1-88 to 1-1-7-89 and continuing. ------------------------------------------------------------------------------------ 2, Where did the damage or injury occur? (include city and county) County Clerk's Office, Martinez, Contra .Costa County. -------------------------------------------------------------------- ----------------- 3. How did the damage or injury occur? (Give full details; use extra paper if required) The County Clerk, J. R. Olsson, and his Deputies have an existing and. continuing conspiracy to deny due process to litigants who are pleading their cases In Pro Per. --------------=----------------------------------------------------=---------------- i4 . What particular act or omission on the part of county or district .officers, servants or employees caused the injury or damage? The County Clerk, J. R. Olsson; and his deputies have a window that is set up for In Pro Per litigants only, and Dean K. Buckley in Case No. C8803354 has been continually harassed, his pleadings have not been filed by the County Clerk and his pleadings have been deliberately lost or misrouted. r .w 5. What are the names of county or distriet-.offi,eers','; servants' or employees causing the damage or injury? ►' '•. :J. R. Olsson, County Clerk, Marilyn ;,Crp,�nl; ,. .t, Assistant County Clerk, and all Deputy County Clerks. 6. What damage or injuries do you claim resulted? ' (Give, full extent of injuries or damages claimed. Attach two estimates 'for' auto 'damage. Denial of rights to due process, conspiracy.. ------------------------------------------------------------------------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage: ) Estimated damages on injuries to plaintiff `s` rights and losses due to the County Clerk's fraudulent actions. , ---------------------------------------------------------------------- -------------- 8. Names and addresses of witnesses, doctors and hospital,. . Contra Costa County Bar Association. I '"s`"told 'by Assistant County Clerk, Marilyn Cramlett, that the Contra Costa County Bar Association insisted that a window be in- stalled for In Pro Per litigants. ------------------------------------------------------------------------------------- 9. List the expenditures you made on account"of this accident or injury: DATE ITEM AMOUNT Not cafcul'ated at' this time. * iF � * � iF � * �F *. iE � iF � 4E * i9E * �F � � 'lE' �U � * �� '..� � •� 9E � � �E �E iE �F� * '� � � * � Gov.,', Code See. 910.2 provides: "The: claim'must be signed by the claimant SEND NGTICES 'I'0 '; ;(At'torne Q' ' I' or b"` some" erson on h-is beh if,'f Name and Address_ of Attorney,_'.`" 1-17-89 Claimant's Signator 883 Hartwick Avenue / Address Turlock, CA 95380 Telephone No. . Telephone No. (209) 668-3427 * * �t'•�t * . * ,W*,`ik' �F.Vit:r.IF NOTICE Section 72 of the Penal .Code 'provides:` "Every person who, with intent' to 'defraud, presents for allowance or for payment to any state board or officer, or 'to':any county, city or district board or officer, authorized to allow or pay, the.^:same Af .genuine, any false or fraudulent v' 1 claim, bill, account, youeher,. or writing,,;•s•is'.�punishable either by imprisonment in the county jail for a period''of. not {more;wtihan?on'e .year, by a fine of not exceeding ,, one thousand ($1,000) , .or by both•"'such:; mpra'sonment""and fine, or. by imprisonment in the state prison, by a fine of not exceed ten thousand dollars ($10,000, or by both such imprisonment and fine. i � Ln .fi o o as co m u w p a4-) cin U rb o ay . c� o � .amu ca '4.) _yy Q L! Y Er^' a) 00Ln W 6 " a ca a w � o s, . al A � ti-+ ONO • 0 m / .mom-C � rO '•� E3, 3 i Ng; •� Z z _ CA r=F3 m. .Ip 1��.!/ X, eoInIeg Aeoea uwnteU Bwsn jo; noA)Iueyl i t CLAIM ` BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT February 28 , 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $399 , 6 6 Section 913 and 915.4. Please note all "Warnir� " l..�urliy Counsel CLAIMANT: RUFUS L. WEBSTER 685 36th Street JAN 2 � 1989 ATTORNEY: Richmond, CA 94804 Date received Martinez, CA 94553 ADDRESS: BY DELIVERY TO CLERK ON January 26 , 1989 Risk Manu, BY MAIL POSTMARKED: January 24, 1989 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. January 27 1989 ppHHIL ATCHELOR, Clerk DATED: + BY: Deputy L, Nall II. FROM/: County Counsel TO: Clerk of the Board of Supervisors (v) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: I BY: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (X This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated:— FEB 2 8 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately, AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: MAR 2 1989 BY: PHIL BATCHELOR by y Clerk CC: County Counsel County Administrator Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public .entity. E. Fraud. See penalty for fraudulent claims, Penal Code S '. . at t e end of this form. RE: Claim By ) Res e or Cler n �Fvs L+ "u>� S� t ED Against the County of Contra Costa ) JAN 2 6 1989 or /11' ) �� PF p,T_ �LOR fG �6Yt)� ��U��JOR District) CL ^K NTS F `_AE Fill in name ) BY •t• __ y The undersigned claimant hereby makes claim a a the County of Contra Costa or the above-named District in the sum of $ ;3 �(� and in support of this claim represents as follows: ------------------------------------------------------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) ---1= ------ -_- -------------------1 = = --------------------------- 2. Where did the damage or injury occur? (Include city and county) ?/_6 _ D I __�A ______________________________________________ 3. How did the damage or injury occur? (Give full details; use extra paper if required) A-'�'- --- D--- '-- 4 C' ==-1D--------------------------------------.. 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? ClCb D O�" � L (over) 5. What are the names of county or district officers, servants or employees causing the damage or injury? -P Y 2019 w.,Lcou) ?A�5_f I (I OA)OLD kb, 64 IKA D LIE---------- j-,--------------f_�6157V 5. What damage or injuries do you claim resulted? (Give full extent of injuries .or damages claimed. Attach two estimates. for auto damage.. -------------------------- --------------------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) ------------------------------------------------------------------------------------- 8. Names and addresses of witnesses, doctors and hospitals. 9. ..List the expenditures you made on account of this. accident or injury: DATE ITEM AMOUNT Gov. Code Sec. 910:2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney.). or by some person on his behalf." Name and Address of Attorney (Claimant's-Signature) Address ql dlto, e,4bAeA)1,4 Telephone No. Telephone No. O'�6 -7�a o� NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for -allowance or for payment to any state board or officer, or to any county, city or district board or, officer, authorized to allow or pay the same if genuine, any falseVorrfraudulent ' claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or .by: ,: both such imprisonment and fine. �� e o aNs Pie 590 6� 98596 ��d 0 plop OQa�\GP 602 22 2 O\a��e0,o5p0 O�eGP X6200 Og95�Ge�A\,b) 51529 016�a�0A 5190 09 �d�1�9s, S E l l 2 2 G° l° �;��ijtclBN� Ca LIJ� �✓1 S c l ✓�C 60 Y G�- 1 �✓J r f goy- Y ' 2 f -- Y UNIQUE AUTO PAINT AND BODY REPAIR 232-7338 2311 Rheem Ave., Richmond, CA 94804 DATE: NAME / �`� ��35���� CAR YR. & MAKE ;s/1 /� ADDRESS_ 2 �'� 7 b ODOMETER CITY ��U" ' PHONE PAINTING LABOR MATERIAL \ y 3 � �Z -70 TOTAL BODY WORK LABOR MATERIAL TOTAL X61 °0 PARTS � � j 3 9' 7(o LABOR MATERIAL 9 TOTAL J r Hou RRSIPD I Mi Lf RIC. °(DR A1LIIIVIIVM TAXABLES I G iii a NO, ERS010 PJ1, CMS 2CEtS:. ?/ 7 SIGNATURE TOTAL .+ -,_,,j.i��..•� �-r .,, u. z>:.y yJrc; _ i d.�)L. •.-..)�r ,Yf.�er'4 y _.5•"e.'`a'-j.p':Y'�';a �d�•-.•„- ..,Yr 1L• ._N 1 s .f...�,...Jt w p 4 AT(3:PAINTINGCONTRA COSTA BODY SHOP BODY REPAIRING 2323 BARRETT AVE. - PHONE 233-6290 ;i RICHMOND' CAL-IF. 94804 "Particular Work for Particular People” -- 0021 4, Xr NAMEy /— u v MAKE / DATE J ''ll ADDRESS_ //A (((���---'I MODEL v C `V� MOTOR CITY _.� -I �/ (1 V —� g� L� / ,/ F'HON ENS � � MILEAGE INSURANCE CO __. —__.__— DEDUCTIBLE— ESTIMATOR, ' SVM. FRONT HRS. PARTS SVM, LEFT HAS. PARTS SVM. RIGHT HRS. PARTS Bumper Up Fender Front I Fender Front Bumper Fender Shld. \ I Fender Shld. Bumper Grd. . Fender Mldg. I Fender Mldg. Bumper Brkt. I Headlamp_ I Headlamp Frt. System _ Headlamp Dr. I Headlamp Dr. Frame, - Sealed Beam I Sealed Beam Cross Mbrs. _ Cowl Cowl Stabilizers Door Frt. �_ Windshield Wheel I Dr.Garnish Mldg. - Door Frt. Hub Cap I Dgor Hinge I r' Dr.Garnish Mldg. Hub & Drum Door Glass i Door Hinges Knuckle Vent Glass. - "'I' Door Glass I Lr. Knuckle Sup. I _ Door Mldg. _ Vent Glass U. Control Arm t- Door Handle I Door Mldg_ ,I Up. Contr. Shft. I Center Post Door Handle Shock, Door Rear Center Post Torsion'Bar Door Glass Door Rear Spring Door Mldg. , Door Glass Tie Rod _ _ Rocker Panel , Door Mldg. Steering Gear Rocker Mldg. JJ I Rocker Panel' Steering WhL Dog Leg zu' Rocker Mldg. Horn Ring 'Guar. Panel Dog Leg Gravel Shld. Ouar. Mldg. Quar. Panel . Park Light I uar. Glass Quar..Mldg; Rad. Shell Quar. Glass Rad. Grille _Ctr: Quar.Innei-Const. ` Rad. Grille Side Quar.-Ext. Grill Mldg. - I I I REAR 4 I Bumper Upper r Air Cond. Core I Bumper` MISC. Dehydrator I ---Bumper Guard Ant i-Freeze Recharge AIC Bumper Brkt.% I Antenna Horn , I Gravel Shld. 6' 1,,I 9 Inst. Panel. ti Baffle Up. i Lr. Panel Frt, Seat Adj. . I Lock Plate Lr. Floor. - Trim Lock Plate-P Trunk Lid Headlining Hood Trunk Light Top Hood Hinges .I Trunk _ Tire Hood Mldg. i ''L, Tail Light Tube - Ornament I Tail Pipe ' I Battery Rad. Sup. I Gas Tank I PainDAylq9P Rad. Core Frame I Under Coat Rad. Hoses I _Wheel_ ' Fan Blade Hub Cap Fan Belt ' Hub & Drum TOTAL LABOR HOURS - d Water Pump. Axle TOTAL LABOR IHR. c,';' (/ Motor Mounts I Spring _ I TOTAL PARTS Trans. Linkage Rear Window - I � TAX a /•r op M ESTIMATE OF REPAIR PAID OUT-Tow & Storag The above js an estimate based on our inspection and does not cover additional parts or labor which may be re- ° quired after the work has been opened up.Occasionally after work has started worn parts are discovered which TOTAL / '/ are not evident on first inspection. Because of this the above prices are.not guaranteed. ESTIMATE' - � r .Ell' 4 q • rte .- � � r �`� y 'y n V , y v 3 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA / Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT February 28 , 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $1, 000, 000 , 00 Section 913 and 91,5.4. Please note all "Warnings". CLAIMANT: CATHERINE GRAINGER County Counsel c/o Ronald P. Golrian _ ATTORNEY: Bradley & Curley FEB 01 1989 100 Bush Street , #2400 Date received ADDRESS: San Francisco, CA 94104 BY DELIVERY TO CLERK ON Januaryart� f15�81 . BY MAIL POSTMARKED: no envelope I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: January 31 1989 PPHHIL BATCHELOR, Clerk BY: Deputy L, Hall 11. FROM: County Counsel TO: Clerk of the Board of Supervisors Y" ) This claim complies substantially with Sections 910 and 910.2. ( } This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: p` BY: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. , FEB 2 8 1989K Dated: PHIL BATCHELOR, Clerk, By eputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown�abbove. Dated: MAR 2 1989 BY: PHIL BATCHELOR by y Clerk CC: County Counsel County Administrator claim.t�: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. if isle l:taiiu 2 aggalris� .Tivi c Li.aii Oiic YuviL CraV1Uy, separate . _L L,3 ,uu.:v v�_- filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code ec. 72 at the end of this form. RE: Claim By ) Reserrvlv amp CATHERINE GRAINGER ) 9 0AN 3 18� Against the County of Contra Costa ) J �� or ) HI A EL R, CLEF UP District) f AQ„ty Fill in name ) By -- - The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ 1,000,000 and in support of this claim represents as follows: ------------------------------------------------------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) October 29, 1989; approximately 9:30 a.m. ------------------------------------------------------------------------------------ 2. Where did the damage or injury occur? (Include city and county) Intersection of Willow Pass Road and Mt. Diablo Street, Concord, Contra Costa County. ------------------------------------------------------------------------------------ 3. How did the damage or injury occur? (Give full details; use extra paper if required) See attached. ------------------------------------------------------------------------------------ i4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? Negligent construction, failure to supervise construction, and failure to properly maintain above-named intersection; negligent design of intersection and use of improper pavement materials. (over) p � 3 . On October 29, 1988 at approximately 9: 30 a.m. , Dan and Catherine Grainger were traveling down Willow Pass Road on their motorcycle. When said parties began to travel through the intersection of Willow Pass Road and Mt. Diablo Street a vehicle nearly struck Mr. and Mrs. Grainger. Due to construction at the intersection, overgrown shrubbery, the intersection design, and slippery pavement tiles, when Mr. Grainger attempted evasive action from the oncoming vehicle, the motorcycle slipped out from under him resulting in injuries to both Mr. and Mrs. Grainger. 7 . a) Estimated present and future medical bills $ 100, 000 b) Estimated present and future wage loss 250, 000 C) Present and future pain and suffering due to knee injury 650, 000 TOTAL $1, 000, 000 8 . Witnesses: Dianna Reidger, 2156 North Sixth Street, Concord, CA 94519; Lynn Spawn, 3105 Fitzpatrick Drive, Concord, CA 94519. List of doctors and hospitals is attached. 9. See attached expense list. T 1 7 � Accident 10/29 Expenses Date Expense Charged By Amount Billed Amount Amount Amount Receipt Of To Metro Paid By Paid By Paid By Expense Date Metro Us Guerrero ---------I----------------------------------------------------------------------------------------------------------------- 11/22/88 Milk of Magnesia Safeway $3.18 11/29/88 $3.18 Y 11/07/88 CPM Machine Dep. Cresent Health Sery $81.75 $81.75 Y 11/11/8B Support Hose Longs Drugs $8.51 $8.51 Y 11/24/88 Tele 10/29-11/9 Pac Bell $72.97 $72.97 Y 11/21/88 Some Care Frances Nilon $36.00 $36.00 Y 11/22/88 Packing Help Frances Nilon $12.00 $12.00 Y 11/14/88 Home Care Frances Nilon $42.00 $42.00 Y 11/16/88 Home Care Frances Nilon $18.00 $18.00 Y 11/06/BB Movies thru 11/12 Video Outlet $12.00 $12.00 N 11/06/88 Movies thru 11/12 Fry's $9.60 $9.60 N 11/05/88 Dinner to Hospital Barney's Hickory Pit $11.75 $11.75 N 10/29/88 Cathy's Levi's $30.00 N 10/29/BB Cathy's undies $6.50 N 10/29/88 Dan's Shoes $40.00 N 11/06/88 Calcium Tabs Fry's $9.53 $9.53 N 11/03/88 Two Gowns Penney's $20.00 $20.00 N 11/03/88 Slippers Penney's $20.00 $20.00 N 10/29/88 Ambulance Service Regional $243.60 11/10/88 $207.06 $36.54 Y 11/I1/8B Pain Pills Fry's $9.10 11/29/88 $9.10 Y 11/17/88 Pain Pills Fry's $9.10 11/29/88 $9.10 Y 11/14/88 Anesthesia Dr. Stein $680.00 11/29/88 $578.00 $102.00 Y 11/22/88 Pain Pills Fry's $9.10 11/29/88 $9.10 Y 11/15/88 Dan's Time Off Work To Date 80 hrs Lost Opportunity Grainger Graphics 12/15/88 Help at 66 Cindy Warner $500.00 $500.00 Y i r 7 � Accident 10/29 Expenses Date Expense Charged By Amount Billed Amount Amount Amount Receipt Of To Metro Paid By Paid By Paid By Expense Date Metro Us Guerrero --------------------------------------------------------------------------------------------------------------------------- Help at GG Frances Nilon 12/16/88 Repairs to MIC Bob Dron HD $2,032.00 $2,032.00 Y (Est) including jacket 10/29/88 Dan's Pain Pills longs $9.10 $9.10 N 10/29/88 Cat Emergency Room Mt Diablo 10/29/88 Dan Emergency Room Mt Diablo $146.41 12/09/BB y 10/29/88 Cat's X-ray Diablo V Radilgy $47.00 12/09/88 $39.95 $7.05 y 11/05/88 Cat's X-ray Diablo V Radilgy $27.00 12/09/BB $22.95 $4.05 y 10/29/88 Surgery Dr. Nottingham $1,720.50 01/12/89 Y 11/18/80 Ortho stocking Hittenbergers $60.00 12/06/88 $60.00 y 12/28/88 Painting Help Steve Nolan $180.00 $180.00 Y 12/31/88 Movers Waters $658.15 $632.00 Y 11/24/88 Pic bike/shoe/pants Longs $4.00 11/29/88 $4.00 N 11/27/88 Cathy's Pain Pills Fry's $8.25 I1/29/BB $8.25 y 11/30/BB Parking Palace Garage $15.00 $15.00 y 12/01/88 Cathy's Pain Pills Fry's $22.20 12/09/88 $18.87 $3.33 y 11/06/88 Cathy's Hosp Bill Mt. Diab Hosp $12,159.19 12/09/88 y 12/17/88 CPM Machine Dep. Cresent Health Sery $75.00 $75.00 Y 12/12/88 Cathy's Pain Pills Longs $7.70 $7.70 Y 12/12/88 Cathy's Pain Pills Longs $15.05 $15.05 Y 11/16/88 Help at 66 Steve Nolan $59.50 $59.50 Y 12/18/88 Excess phone bill Pac Bell $100.00 $100.00 Y Normal bill is between $50 & $60 10/29/88 Mt Diab Hosp $86.00 12/01/88 $73.10 $12.90 Y 12/12/88 Cathy's Pain Pills Longs Drugs $15.05 01/12/89 $15.05 Y 12/09/88 Cathy's Pain Pills longs Drugs $7.70 01/12/69 $7.70 Y r r Accident 10/29 Expenses Date Expense Charged By Amount Billed Amount Amount Amount Receipt Of To Metro Paid By Paid By Paid By Expense Date Metro Us Guerrero --------------------------------------------------------------------------------------------------------------------------- 12/23/BB Cathy's Pain Pills Fry's $13.10 01/12/69 $13.10 Y ------------------------------------------------- Total Expenses $19,352.59 $939.93 $2,251.91 $2,032.00 QTY. UNIT PRICE DESCRIPTION AMOUNT 3.� AMBULANCE INC. 7.tEET FFiEMON7,CA 94538 :�� J>fiSCHIAELi'S A: CWtAVLc• -1 NC-0: I?t9©364Z DIV. OF .AMS AONT,CA 94537-7780 - _:uiTUP -AMEDA COUNTY ONTRA COSTA COUNTY Key ): '•'�• =-`�3G � �'A -�!' . 0 FREMONT,CA 94537-7780 aw!r 2Fi3 .R3Y4: 3TAV: 13 tw 1 SUPPLIES AND RENTALS �;,�.,7yR.• it•�j U c J—WHEELCHAIR SERVICE SEE REVERSE SIDE FOR FlNANCE TERMS 8 BILLING ASSISTANCE AMOUNT DUE Z 4 J•b 0 TRIP NO. CALL RECEIVED FROM Fp;:" NEED OF J>yZJ 7 H�� I A. L ; '7 T T. DI Ac:L J h0': �?. NJURY .`.,;,TC./�.C%. NO. '-�1217i - i v.= • J�::: V/SA 1882 ALICANTE GT( 'I ..L.• �' 6 VGt-.y•✓'�V• Irn -44720 DBY : C ,.T T, r1 E D r r,rirlrrlr;r)� r:A 94 r.) PHONE TAX I.D. 41 5--66-.112--1 Q1. 1 TICS:; 94--71340947 l.,i�r;), TO REMIT TO 1"iAN T['J-. t:,F;A T Nrir,'F; -RORFFiT .7.. ATF T rl M, f1; Y T rIC P.Jr—ANTF. COURT 2299 SA-r.'ON ST.SUITE #9 94521 CONCORD, C4945?0 PLEASE RETURN UPPER PORTION WITH YOUR PAYMENT PLEASE RETAIN THIS PORTION FOR YOUR TAX RECORDS FROM ACCOUNT DATE r"(71!- -0--RT .],. ,TF T NI M, n , T 1.17 ,4792 11 /14/-?i: S 179 AT; MT, nSARI.. ► H.ngF*lTA!.. TN PT PATIENT F:F f'nFIY P� NOTT T�IGHAM !'ATNF.RTNF r;F A T rIr1FF; SERVICE . • CODE DESCRIPTION CODE t•r-)i^9 ink? 7 ^75. 6-34 OPEN RED, MT, FX 6R0. ()(,)-4- r i(;).a. RTGHT TTE+TAI.. PI.ATFAU ***Ali!- THESIA T MF*** 3 HR.S„ 20 M N..,. * SEE REVERSE FOR EXPLANATION OF CODES 'WIT HAVE RTI. -17-P YrJI.)F; TN9!)FeAMCF; ` ' �' .17 690: or. •1F*•1F•1F 1 �.1 • ■ L L l 614 AJC_4rS 66 �- �• ss �- o M t o r► '�=z t'• V4000 �- • 4D • i r i • r i C% F PACIFIC' BELL_ A Pacific Telesis Company Account Number 415 672-7312 546 N 7 Page 5 Statement Date Nov 8,1988 /AT • Questions lFor billing questions call: No Charge 1 800 222-0300 Calls Itm Date Time Min * Place and Number Called Charge 1 Oct10 419P 4 DD SACRAMENTO CA 916 448 1501 .84 2 Oct10 752P 1 DE LAS VEGAS NV 702 389 3968 .19 3 Oct17 1143A 1 SD SAN FRAN CA - 397 5533 From 2.06 KINGMAN AZ Calling Card 4 Oct18 211P 2 SD SAN FRAN CA - 397 5533 From 1 .38 GRNDCN AZ Calling Card 5 Oct18 213P 2 SD SAN FRAN CA - 477 6431 From 1 .38 GRNDCN AZ Calling Card T14Oct26 630P 10 DE VAN NUYS CA 818 784 5712 2.04 Oct29 342P 1 DN WLOSANGELS CA 213 472 7687 .23 Oct29 349P 1 DN VAN NUYS CA 818 784 5712 .23 Oct29 350P 7 DN STOCKTON CA 209 477 6214 .82 Oct29 357P 8 DN CLMNTSNDMS CA 714 596 2878 1 .24 Oct29 405P 1 DN SANFRNANDO CA 818 360 7372 .22 Oct29 125P 1 SN WLOSANGELS CA 213 472 7687 From .73 CONCORD CA Calling Card Oct30 834P 13 DN WLOSANGELS CA 213 472 7687 1 .96 Oct31 937P 9 DE WLOSANGELS CA 213 472 7687 1 .84 Nov 1 813P 11 DE VAN NUYS CA 818 784 5712 2.23 Nov 1 827P 3 DE LAS VEGAS NV 702 388 2028 .52 Nov 1 851P 9 DE STOCKTON CA 209 477 6214 1 .39 18 Nov 2 907P 9 DE VAN NUYS CA 818 784 5712 1 .84 19 Nov 3 754P 7 PE WLOSANGELS CA 213 472 7687 �G 20 Nov 4 841P 8 DE STOCKTON CA 209 478 3050 1 .24 21 Nov 5 217P 19 DN WLOSANGELS CA 213 472 7687 2.82 22 Nov 7 827A 1 DD WLOSANGELS CA 213 472 7687 .39 23 Nov 7. 301P 6 DD WLOSANGELS CA 213 472 7687 1 .59 24 Nov 7 352P 1 DD LAS VEGAS NV 702 389 7338 .30 .25 Nov 7 355P 1 DD LAS VEGAS NV 702 389 3968 .30 26 Nov 7 356P 2 DD LAS VEGAS NV 702 388 2028 .55 27 Nov 9 852A 1 DD LAS VEGAS NV 702 389 3968 .30 28 Nov 9 853A 1 DO LAS VEGAS NV 702 389 7338 .30 29 Nov 9 905A 2 DD LAS VEGAS NV 702 388 2028 .55 30 Nov 9 910A 1 DD LAS VEGAS NV 702 368 4114 .30 * See Rate Key on Reverse Call Subtotal $31.24 Monthly Itm Charge Charges and 31 State Surcharge .91 Credits 32 California Regulatory Fee .02 33 Billing Surcharge .37a 34 Communication Devices Funds for Deaf and Disabled .12 35 Tax: Fed: .96 911 : .12 1 .08 Monthly Charges and Credits Subtotal $1.76 Total AT&T Current Charges $33.00 This portion of your bill is provided as a service to AT&T. There is no connection between Pacific Bell and AT&T. You may choose another company for your long distance calls while stili receiving your local telephone service from Pacific Bell. 6 357 SP47 4156727312546 N 7 9020A 94521 CR24 167 9053 3385 PACIFIC1' BELL., A Pacific Telesis Company Account Number 415 672-7312 546 N 7 Page 3 Statement Date Nov 8,1988 Pacific Bell Service Itm Date Time Min * Place and Number Called Charge Area 1 Calls 1 Nov 3 335P 14 SD SAN FRAN CA - 477 6431 From 2.73 Continued CONCORD CA Calling Card 2 Nov 3 356P 6 SD OAKLAND CA - 655 3096 From 1 .27 CONCORD CA Calling Card 3 Nov 4 508P 1 DE SAN FRAN CA - 922 5040 .17 4 Nov 4 1049P 5 SE CONCORD CA - 672 0627 Coll 1 .31 5 Nov 4 1008A 1 SD SAN FRAN CA - 434 2901 From .65 CONCORD CA Calling Card 6 Nov 4 1115A 10 SD SAN FRAN CA - 434 2901 From 2.09 CONCORD CA Calling Card 7 Nov 4 151P 16 SD SAN FRAN CA - 434 2901 From 3.05 CONCORD CA Calling Card 8 Nov 4 820P 2 SE SAN FRAN CA - 397 5533 From .68 CONCORD CA Calling Card 9 Nov 4 822P 3 SE SAN FRAN CA - 397 5533 From .79 CONCORD CA Calling Card 10 Nov 4 832P 20 SE SAN FRAN CA - 397 5533 From 2.70 CONCORD CA Calling Card 11 Nov 5 912P 23 DN SAN FRAN CA - 922 5040 1 .50 12 Nov 5 1220P 7 SN SAN FRAN CA - 397 5533 From .88 CONCORD CA Calling Card 13 Nov 7 858A 1 DD SAN FRAN CA - 362 8783 .25 14 Nov 7 927A 12 DD OAKLAND CA - 339 2810 1 .65 15 Nov 7 1031A 12 DD SAN FRAN CA - 434 2901 2.01 16 Nov 7 337P 1 DD OAKLAND CA - 339 1174 .22 17 Nov 8 821P 2 DE OAKLAND CA - 547 3829 .24 18 Nov 9 815A 4 DD SAN FRAN CA - 434 3080 .73 19 Nov 9 855A 3 DD SAN FRAN CA - 956 3169 .57 * See Rate Key on Reverse Service Area Call Subtotal $60.74 Zone 2 Itm Date Time Min * Zone Place and Number Called Charge and 3 Calls 20 Oct29 407P 10 DN 2 DANVILLE - 866 1205 .10 21 Oct30 1247P 1 DN 3 BERKELEY - 540 5153 .04 * See Rate Key on Reverse Zone 2 and 3 Call Subtotal $.14 Regulated Itm -- - - Charge Other Charges and 22 Credit for Over Billing of Taxes .54at Credits for Monthly Services on Oct. 1988 Bills Regulated Other Charges and Credits Subtotal 8.94cR Regulated Itm Charge Monthly Charges Basic Service and 1 Flat Rate Service 8.35 Credits Optional Service(s) 1 Touch-Tone Service 1 .20 6 357 SP47 4156727312546 N 7 6020A 94521 CR24 167 9053 3385 r PACIFICrBELL_ A Pacific Telesis Company Account Number 415 672-7312 546 N 7 Page 2 Statement Date Nov 8,1988 PACIFICEIBELL_ • Service Itm Date Time Min * Place and Number Called Charge Area 1 Calls 1 Oct11 616A 1 DN DANVILLE CA 829 1795 .08 2 Oct11 426P 4 DD LOWER LAKE CA 707 994 4640 1 .33 3 Oct11 441P 1 DD OAKLAND CA - 339 1174 .22 4 Oct11 442P 3 DD SAN FRAN CA - 397 5533 .57 5 Oct11 444P 1 DD SAN FRAN CA 434 2901 .25 6 Oct11 928P 1 DE RICHMOND CA - 222 3851 .15 7 Oct1I 1235P 1 SD MARYSVILLE CA 916 673 0676 From .74 SACRAMENTO CA Calling Card 8 Oct14 330P 4 DD SAN FRAN CA - 397 5533 .73 9 Oct14 333P 1 DD SAN FRAN CA - 477 6431 .25 10 Oct14 334P 1 DD SAN FRAN CA - 477 6431 .25 11 Oct14 349P 1 DD SAN FRAN CA - 477 6431 .25 12 Oct14 349P 1 DD SAN FRAN CA - 397 5533 .25 13 Oct14 459P 1 DD RICHMOND CA - 222 3851 .22 14 Oct14 638P 10 DE RICHMOND CA - 222 3851 .97 15 Oct18 1005A 2 DD RICHMOND CA - 236 9111 .35 16 Oct21 914A 1 SD W ANGELES CA 213 472 7687 From .80 BARSTOW CA Calling Card 17 Oct24 757P 9 DE UKIAH CA 707 468 5233 2.01 18 Oct27 630P 6 SE CONCORD CA 672 0641 Coll 1 .36 19 Oct28 715P 1 DE SAN FRAN CA - 922 5040 .17 0 Oct28 735P 1 DE HAYWARD CA - 537 5228 .17 Oct29 345P 4 DN UKIAH CA 707 468 5233 .53 22 Oct29 502P 3 DN VALLEJO CA 707 557 4293 .16 23 Oct29 613P 3 DN SAN FRAN CA - 673 1281 .22 24 Oct30 1106A 19 DN DANVILLE CA - 829 1795 1 .02 25 Oct30 226P 2 DN PLEASANTON CA - 462 1309 .15 26 Oct30 804P 24 DN SAN FRAN CA - 922 5040 1 .57 27 Oct30 751A 7 SN VALLEJO CA 707 557 4293 From 1 .32 CONCORD CA Calling Card 28 Oct31 704A 2 DN SAN FRAN CA - 434 2901 .16 29 Oct31 928P 9 DE SAN FRAN CA - 922 5040 1 .07 30 Oct31 1055A 1 SD SAN FRAN CA - 362 7489 From .65 CONCORD CA Calling Card 31 Oct31 1057A 2 SD SAN FRAN CA - 421 3120 From .81 CONCORD CA Calling Card 32 Oct31 253P 12 SD SAN FRAN CA - 477 6431 From 2.41 CONCORD CA Calling Card 33 Nov 1 1131A . 1 DD RICHMOND CA - 222 3851 .22 34 Nov 1 1155A 1 DD SAN FRAN CA - 397 5533 .25 35 Nov 1 1157A 3 DD OAKLAND CA - 465 1848 .48 36 Nov 1 1208P 4 DD BENICIA CA 707 745 5018 .38 37 Nov 1 1212P -2 -DD SAN -FRAN ---CA ----397 5533 -------- --,41 38 Nov 1 1214P 3 DD SAN FRAN CA - 362 5758 .57 39 Nov 1 1218P 2 DD SAN FRAN CA - 397 5533 .41 40 Nov 1 759A 2 S3 SAN FRAN CA - 434 2901 From .66 CONCORD CA Calling Card 41 Nov 1 817A 8 SD SAN MATEO CA - 342 2610 From 2.25 CONCORD CA Calling Card 42 Nov 1 911A 1 SD OAKLAND CA - 452 4911 From .62 CONCORD CA Calling Card 43 Nov 1 1101A 13 SD SAN FRAN CA - 477 6431 From 2.57 CONCORD CA Calling Card 44 Nov 2 1006A 32 SD SAN FRAN CA - 477 6431 From 5.61 CONCORD CA Calling Card 45 Nov 3 1102A 2 SD SAN FRAN CA - 477 6431 From .81 CONCORD CA Calling Card 46 Nov 3 115P 2 SD SAN FRAN CA - 362 7269 From .81 CONCORD CA Calling Card 6 357 BP47 4156727312546 N 7 6020A 94521 CR24 167 9053 3385 73 T mmorsw nj U PHARMACY 5100 CLAYTON RD.,CONCORD,CA 94520 (415)$27.9295 Date NOV a? P00Phone 4 rS 827-929HOURS IF NEEDED FOR PAIN CLAYTON D., CONCORD, CA. 303635 DOct DR JACOBSEN TORS -100 30 CATHY GRAINGER HYDROCODONE/APAP 5/ 11-27-88 10-90 GENERIX DL TAKE I TO 2 TABLETS EVERY 4 DISCARD AFTER HOURS IF NEEDED FOR PAIN MAY CAUSE DROWSINESS RX I NO ALCOHOL HYDROCODONE/ApAp 51`00-1 25 DISCARD AFTER GENERIX Sm -KLASE READ THE ABOVE DRUG INFORMATION FIX 'MAY CAUSE DROWSINESS ti NO ALCOHOL 1802 ALICANTE CT 672 7312 LAST FILLED ON 11-17-88 0 CALL IN ADVANCE FOR REFILLS RX KIASE READ THE ABOVE DRUG INFORMATION THANK YOU FOR YOUR PATRONAGE I802 ALICANTE CT 672 7312 S 9.10 182-1765- 1 LAST FILLED ON DR MUST OR REFILLS. ALLOW TIME CALL IN ADVANCE FOR REFILLS 0 Order Total $ THANK YOU FOR YOUR PATRONAGE Save This Receipt For Tax and Insurance Records. 8.25 182-1765- 1 S. IF YOU LIKED OUR SERVICE IF YOU LIKED OUR SERVICE, PLEASE TELL YOUR FRIENDS! PLEASE TELL YOUR FRIENDS! THANK YOU FOR SHOPPING fWu4`ws7 THANK YOU FOR SHOPPING fr a w 6 ivs, tV 40 -q t,4 -1 f-.) CDt- tri Im 2> o 0 a 0 C m 0 1:23 0 W. < M ar 0 0M C> 0 m m o I :> mac s a tX2 00 0 = rri O9 tv It c:, Z O C6 P* 0 0, , :0 - MCLS 0 -v r C11 w j 8) t. In LOW 0C3 0 PO Ln V Xf "to yl 00 C& N CM, 4 IQ 44 C M epi 0 4vs PHARMACY 5100 CLAYTON RD.,CONCORD, CA 94520 (415)827.9295 PHARMACY 8y9295 5100 CLAYTON BLVD., CONCORD, CA. . 302992 DR NOTTINGHAM PA CATHY GRAINGER 11-11-88 TAKE 1 TO 2 TABLETS EVERY 4 HOURS IF NEEDED FOR PAIN HYDROCODONE/APAP 5/500 30 9-90 GENERIX DL DISCARD AFTER MAY CAUSE DROWSINESS J PLEASE READ THE ABM DRUG INFORMATION -- 1802 ALICANTE CT 672 7312 CALL IN ADVANCE FOR REFILLS THANK YOU FOR YOUR PATRONAGE S 9.10 182-1765- 1 DR MUST OK REFILLS, ALLOW TIME Order Total $ _ Save This Receipt For Tax and Insurance Records. IF YOU LIKED OUR SERVICE, PLEASE TELL YOUR FRIENDS! ���� THANK YOU FOR SHOPPING } S i a HAPPY HOLIDAYS FROM SAFEWAY. YOUR SPECIAL PLACE TO SHOP.931 PHILLIPS MOM 2.19 T TAX BALANCE DUE 3.18 CASH TENDER 3.18 ' CHANGE DUE .00 11/22/88 .21'.37 LANE 7 202 F,- r. r FOOD Rtitl DRUG - -, t"'VTON RLQ "r'2 ?.8F'M -ti TORE 4AM "7REG 15 OPR 4000,1 moo�► VALLEY� BLVD. r�na .CA 04521 PHONE 872-0846 i GRAINGER, CATHY 1802 ALICANTE DR CONCORD, CA''94�i21 VWM STS c�F'E 4 r,*.,RT 25 ISS REG C.t?CK fUNI NOTTINGHAM, R---MD LOC CED _PRI CE $15. 05 #40 VICODIN TABLET . (KN) . NDC#00044—DX24—O2-. EDS 5 REG # ZKO19537 ? 2 5PPI STtIP. 4 _ F,'PT 15 ME. RE6 U71--K--lt4L UNL FRMS'FOOD RNr% PR 61 510.0 r"L RI TOM EF', tCS 7.. 39 REG 1.5 OPR 4130.0.7 MW YGNACtO VALLEY BLVD,#C CONCORD,CA"S21 PHONE 872.4846 't.1 F'*-'t1/_t 14PRIP T,`;' _ 12/09/88 R x 4* n 1 1 E5 E3`7 C44) k.,T[•,RY 8014 2-517 . 619 TN" GRAINGER, CATHY TOTAL 15 4 1802 ALICANTE DR 'F?SN TEN.C� �3!t. 1� CONCORD, CA 94521 t, Sl IRTOTAL 15. �,8 •• •• � 40TT I NGHAM,--DR' MD • • ' 'PRICE $7. 70 .4. FOR CHPN13E . 1.5 VICODIN .TABLET BEST WIL I DP r' NUSHE=r (KN) C#00044-0727-02 EDS 3 3 # ZKO19537 t Jigo �• `{ r�'v ic Sx a tat i C] Q ; LoCIA - H " co ; t b � c+7 r� 4 � Q x [=7 ra3 y �`i, 3 xa US� 3 V FC r a 'p (� cr,• i GPAING M, CAIIIWILU7. HOME 415-f 72-7317 1802 Alicante CourtBus. 415-395-5533 Concord, CA 94521 EMPLOYER Sal -Grapbi ,e T)PAignpr SEND BILL TO. Patient PAUL B. NOTTINGHAM, M.D. toy J.n Jul Au9 SOV Oct Nov Dec ORTHOPEDIC SURGERY ,_� 2222 EAST STREET, SUITE 305 CONCORD, CALIFORNIA W20 ` (415) 676-1209 <...> r.-- Statement To: Catherine Grainger 1802 Alicante Court Concord,CA 94521 For Patient: DOB: 09-30-55 SS#: 546-15-5587 DAL. trwD.� FAMILY CREDITS CURRENT DA�TE MEMBER DESCRIPTION /CHARGE WAVNENTS ADI. BALANCE //l� '/ 0 so DATE DOCTORCODE DESCRIPTION AMOUNT 11-05-88 D KAPLAN. N.D. ,INC 73564.26 KNEE COMPLETE 27.00 HOURSOUR QEEICE R FROM 9:00-12:00 & 1:00-4:30 ACCOUNT NUMBER DATE OF STATEMENT AMOUNT PAID PAYMENTS AFTER THIS YOUR NEXT STATEMENT0. 1072396 12-29-88 27.00 PATIENT NAME HAVE YOUR HEARD FROM YOUR INSURANCE CO? WE HAVEN'T. PLEASE SEND US THE BALANCE DUE TODAY. , CATHERINE GRAINGER THIS REMAINS YOUR ,RESPONSIBILILTY. MAKE CHECKS PAYABLE TO: DIABLO VALLEY RADIOLOGY MED GRP Tax I11 94-1235694 L JERONE LEWIS NO INC PAUL E .NORRIS NO APC PISCO of 60rvie0: NT OIAtLO HOSPITAL I/P RONALD A WEINTRAUB NO APC NOMARD E COHEN NO INC Referring Dotter: NOTTIMONA14 P DANIEL KAPLAN NO INC -DAVID WINSON NO INC elognovLs: •li.t0 RICHARD SAYS[ NO PC JACOB EPSTEIN NO INC ROBERT A CLARK NO INC COWARD MILLER N0 INC DIAiLD VALLEYRAQIOLOCY *ED CRP RICHARD N SIGEL NO INC WILLIAM NDDOICK 'N0 0.0. 4811 Soli SAN .CANON CA 44593 �, alliiA-tA3S . hNii 4 t 5y SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION Y 's� AMOUNT 10-29-88 DONALD COVEN, M.D. 73560.26 KNEE LIMITED 20.00 10-29-88 DONALD COVEN, N.D. 73564.26 KNEE COMPLETE 27.00 . ACCOUNT NUMBER DATE OF STATEMENT AMOUNT PAID PAYMENTS AFTER THIS DATE WILL APPEAR ON — YOUR NEXT STATEMENT PATIENT NAME HAVE YOUR HEARD FROM YOUR INSURANCE CO? ME HAVEN'T. PLEASE SEND US THE BALANCE DUE TODAY. THIS REMAINS YOUR RESPONSIBILILTY. MAKE CHECKS PAYABLE TO: DIABLO VALLEY RADIOLOGY MED GRP Tax Id 94-1235894 L JEROME LEWIS NO INC PAUL t MORRIS NO APC Place OP service: NT DIABLO HOSPITAL I/P RONALD A WEINTRAUB NO APC HOWARD E COVEN MD INC Referring Doctor: SARACHEK MD DANIEL KAPLAN MD INC DAVID WIxSON NO INC Diagnosis: 710.46 RICHARD SAYRE NO PC JACOB EPSTEIN NO INC ROBERT A CLARK ND INC EDWARD MILLER MD INC DIABLO VALLEY RADIOLOGY RED ORP RICHARD M SIGEL MD INC WILLIAM NODDICK' MD P.O. BOx SOli SAN RAMON CA 94303 A1S/066-0435 SEE REVERSE SIDE FOR IMPORTANT EI LLING INFORMATION r- 1 I 976855-1 DR . NOTTINGHAM 1 /13/89 DRESS FOR LESS 4027902 KATHY JhAIh,;ER 39755332 TAKi ONE TABLET THREE SAVINGS COME IN ALL SIZES TIMES A DAY "WENEElC MOTRIN I E JPt.OFF►v 8@QMG BOOTS 30 $ 9.97 WTM OYY MCK _ cwov,17 A 82k-0173—o5 - CALL F.EFILLS 1 DAY IN AI ANi,E C U S T M E R c 976656-1 DR. NOTTINviAh 1/13;E0 m,ATHY GRAINGER ;:=07F TAKE ONE TALLrT EV10 3-4 Y TOURS AS NEEDEL TOR P, IN GENERIC VICODiN APAP/HYDROCODONE ThE 3ARii i5 7.55 kIM YOI MCK 555-0325-04 CALL REFILLS 1 DAY IN . i L.4 TRANS.C'.)DE TOT AL i CIPt OYER SIGNATURE o . 8 t me o T� T l "�� �. _E � � Nr: wc ,ti . x- �► � x tit-- � � 5 _ :,_ : .,- �� {] \,N The 188118r d the�d IdenWieiorrlhlKipem i6 authorized to pay the BMWrTt * '` c' .-- .s �n i c c �' moOIAL wn ee.,iTMOTAI—1\ with thet� `j sLbpd to and in acro danccee if �o c a G �p • C x 1 pommm the the d each card. X V O �N � `� �p IV tb I'" ! I L:7 ATION C H T a. Trr CG 711.11.1TL ST @IGMATURE FODE #AD8E RECD BY: 8082 2.88 } r y-r .• "Aw'i 9f:±'r:`,:•�:~ I �',q:... +ai``9k`-W`RTr' qe_`a �^'��:=�'; ?'!ti', �'�"i,�Ca�`G<:)?:'..i- '�n.'"r'Y.�.. 4Lt �` MRtNlOCUI ALANNAMt 7 4 V ATTENDING PHYSICIAN'S STATEMENT 1974 California Standard Nomendature O D/C one of Senior �O aA OFFIC[flRVICES NEW [STAB FEE ©CONSULTATION wine@ Hasp FEE WN of iN�ry / / Brief 90000 Limited ( ) ( ) 90601) IDta Limited 90010 90060 Extensity ( ) ( ) 90610 Intermediate 90015 Comp.H&P ( ) ( ) 90620 Follow-Up 90050 By Report 90630 Extended Re-Exam 90070 Seen•Request oft Non-Cancelled Appt. 99049 Q OTHER SERVICES CODE FEE J❑HOSPITAL VISITS Initial Subseq FEE QINJECTIONS Brief or Limited 90200 Injection/major Intermediate 90215 Injection/Minor r Comprehensive 90220 Aspiration at Visits • 90250 Admlt--_/ /Discharge_/ ©MATERIALS C CASTS Under 10 Over 10 Detention Time 99040 Long Arm 29060 29065 99070 ©SURGERY CODE FEE Short Arm 29070 29075 Cylinder 29360 29365 Long Lag 29340 29345 Short Leg,Walking 29420 29425 Short Log ` 29400 29405 , OD SPLINTS OH X-RAYS: Long Arm 29100 29103 Short Arm' 29120 29125 Long Leg 29500 29503 r Short Leg 29510 29513 Please a((aty thele QO others: I Vogt latrraaee PV to arbmit to form:end _ f roar lairranee DIAGNOSIS: ja& Please Retain Pink TOTAL FEE 3 Copy For Your Personal Financial Recofds. Attach Yellow Copy To Your Insurance Form and Process For Benefits. AUTHORIZATION TO PAY BENEFITS TO PHYSICIAN: 1 hereby certify the above named services were . S S N#5 5 4—7 0—2 81 7 rendered and direct that payments be made to the physician named hereon. I understand I am financially CA LIC#G 0 4 6 0 2 ►uporisible for charges not covered by my Insurance. PAUL B. NOTTINGHAM, M.D. Signed Date ORTHOPEDIC SURGERY Insurance Carriers—This form has been adopted to keep paper work Costs down.If any additional Mans 2222 EAST STREET, SUITE 305 or itendsed bills are required they will M Completed upon the reaelpt of 81 SAO. NEXT eat, CONCORD, CALIFORNIA 94520 RETURN: Sys Weeks_ Months APPT. P.M. (415) 676-1209 Day Month Date Time I 1026 Oak Grove, Suite #4 Concord,California 1 f Telephone(415) 671-7771 SINCE .0 I N V O I C E TO: DAN GRANGER FROM: HITTENBERGERS 6040 GREENARMS DRIVE 1026 OAK GROVE #4 OAKLAND, CALIFORNIA, 94611 CONCORD, CALIF., 94518 ATT. ERIC GREEN DATE OF SERVICE DESCRIPTION COST 12-6-88 REPLACE FLEXIBLE INNER SOCKET $600.00 12-6-88 ADDITION TO LOWER EXTREMITY SUCTION SUSPENSION $139.00 12-6-88 REFINISH FLEX FOOT PROSTHESIS 3HRS. TECHNICIAN @ 45.00 P/HR. $135.00 TOTAL DUE $874.00 CERTIFIED BY THE AMERICAN BOARD FOR CERTIFICATION IN PROSTHETICS AND ORTHOTICS s t C k: it r• _ FORM APPROVED _ OMB NO 0938-0008 PLEASE-DO NOT STAPLE'IN THIS ARES HEALTH INSURANCE CLAIM FORM (CHECK APPLICABLE PROGRAM BLOCK BELOW) Lj MEDICARE MEDICAID CHAMPUS CHAMPVA FECA BLACK LUNG OTHER )MEDICARE NO 1 (MEDICAID NO,) )SPONSOR'S SSNI IVA FNE NO I ISSNI '(CERTIFICATE SSNI ' PATIENT AND INSURED (SUBSCRIBER) INFORMATION 1,PATIENT'S NAME(LAST NAME,FIRST NAME.MIDDLE_IN1TI AL) '^ 2.PATIENT'S DATE OF BIRTH - 3.INSURED'S NAME(LAST NAME.FIRST NAME,MIDDLE INITIAL) r_,.RATNrFa CATHERINE 09 1 30 55GRAINrER, ",DANIEL 4.PATIENT'S ADDRESS(STREET,CITY,STATE,ZIP CODE) - 5.PATIENT'S SEX .8.INSURED'S ID NO.(FOR PROGRAM CHECKED ABOVE.INCLUDE ALL LETTERS)) r 1802 ALICANTE COURT I MALE FEMALE X26568^�� rnNrORn � rA 94521 T.PATIENT'S RELATIONSHIP TO INSURED 8,INSURED'S GROUP NO.IOR GROUP NAME OR FECA CLAIM NO.) SELF -SPOUSE CHILD OTHER 6597'6 672-731 2 a El D HEALTH PLIS`HMPLOYED AND COVERED BY EMPLOYER W OTHER HEALTH INSURANCE COVERAGE(ENTER NAME OR POLICYHOLDER 10.WAS CONDITION RELATED TO PRESS(S7pEA. IaY,S� C®E; R AND PLAN NAME AND ADDRESS AND POLICY OR MEDICAL - ! I. L !�,•�F 7 i�. IR. L SER . ASSISTANCE NUMBER) A.PATIENT'S EMPLOYMENT YES F-] .X❑. NO TELEPHONE NO-672-7.112 6.ACCIDENT I I.e. CHAMPUS SPONSOR'S ACTIVE BRANCH OF SERVICE STATUS AUTO OTHER 1 O DUTY DECEASED i .:1 Q RETIRED . 12.PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE(READ BACK BEFORE SIGNING) 13.1 AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO UNDERSIGNED PHYSICIAN OR SUPPLIER FOR SERVICE DESCRIBED BELOW 1 AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM I ALSO REQUEST PAYMENT OF GOVERNMENT BENEFITS EITHER TO MYSELF OR TO THE PARTY WHO ACCEPTS ASSIGNMENT BELOW SIGNED gTQN,AT!lRE ON. FILE DATE SIGNED(INSURED Oh AUTHORIZED PERSON) PHYSICIAN OR SUPPLIER INFORMATION 14 DATE OF: ILLNESS(FIRST SYMPTOM)OR INJURY 15.DATE FIRST CONSULTED YOU FOR THIS 18.IF PATIENT HAS HAD S/MME OR. 18.4.IF EMERGENCY HE NCV :ACCIDENT)OR PREGNANCY(LMP) CONDITION SIMILAR'ILLNECS OR 1 UpY,'G1YE DATES � CHECK E 17.DATE PATIENT ABLE TO 18 DATES OF TOTAL DISABILITY DATES OF PARTIAL DI.SABILII y RETURN TO WORK 1 FROM ITHROUGH FROM 'THROUGH 19.NAME OF REFERRING PHYSICIAN OR OTHER SOURCE(e.g..PUBLIC HEALTH AGENCY) 20,FOR SERVICES RELATED TO HOSPITALIZATION GIVE HOSPITALIZATION DATES P -NO TT I NrHAM ADMITTED10/29/88 I DISCHARGED 21.NAME 8 ADDRESS OF FACILITY WHERE SERVICESRENDERED(IF OTHER THAN HOME OR OFFICEI 22.-WAS LABORATORY WORK PERFORMED OUTS,DE YOUR OFFICE? MT DTRI n HOSPITAL IN PT YesaflNO CHARGES L) .-nnOO A, 23.DUIDNOSIS OR NATURE OF ILLNESS OR INJURY.RELATE DIAGNOSIS TO PROCEDURE M COLUMN D BY REFERENCE NUMBERS 1,2,3,ETC.OR OX CODE B. EPSDT .` _YES r r 71 NO 2' "FAMILY PLANNIN'' YES a - ❑NO 3. __-__________________________________ PRIOR 4. AUTHORIZATION NO. 24. A C FULLY DESCRIBE PROCEDURES.MEDICAL SERVICES OR SUPPLIES D - -E ` F G• H LEAVE BLANK DATE OF SERVICE PLACE FURNISHED FOR EACH DATE GIVEN - - DAYS- FROM 7p OF PROCEDURE CODE IE%PLAIN UNUSUAL SERVICES OR CIRCUMSTANCES) DIAGNOSIS OR T.O.S ' SERVICE,(IDENTIFY: )_ CODE CiHARGE$,, UNITS 102988 1 27536-34 OPEN _RED _ INT - .F X. 6,80 x.00 14 RIGHT TIBIAL PLATEAU "i - - 000S4 ** - ANESTHEG'IA TIME, , 3 HOUR- 20 MINUTE MODIFIER 34 EXPLAINED. 3'4=._.EMERGENCY FULL`., B OMACH. WITH TUBE .., - r 1 25.SIGNATURE OF PHYSICIAN OR SUPPLIER(INCLUDING DEGREE(S) 28.ACCEPT ASSIGNMENT(GOVERNMENT 27,TOTAL CHARGE 1 28.AMOUN7 PAID -• 29.'%BALANCE DUE OR CREDENTIALS)(1 CERTIFY THAT THE STATEMENTS ON THE CLAIMS ONLY)(SEE BACK) REVERSE APPLY TO THIS BILL AND ARE MADE A PART THEREOF) I 680 0'd >;1cVES�.a y NO 31.PHYSICIAN'S SUPPLIERS AND OR G OUP.NAME ADDRESS.ZIP CODE AND TELEPHONE NO. '"•' 3o.YOUR SOCIAL SECURITY NO =:..�.,,..,_.• ROBERT. J .��S-TIE'i.N(--'NI=a©: ;INC` / stn:. • 2299 BA0'01, ''�'1� S,UI'TE:''*9• _ 12/08/88 CnNCORl ? CN 945.20— 32.YOUR PATIENT$ACCOUNT NO. _ ly 1^tqs ) ,�t 33.YOUR EMPLOYER.IQ,NO y ,t 415-682 .1.911. GRAC764292 C018DC INFR. .00 IRS 94-2:4•$19'41-)'- 1`. ,DNo, . O,OC221291d'=` rv" *PLACE OF SERVICE AND TYPE OF SERVICE(T.O.S.)CODES ON BACK "APPROVED'Af AMTA'COUNCIL' FORM HCFA-'f 00•(1-84)OORM OWCP 1500 REMARKS N �tAp MED14'J1}.BERVICE 6/83 FORM CHAMPUS-501(1-84)FOgAtFRS SW ' FORM AMA OP6503 v 9' .ja CA,y, s :C Mme,, _ .,. ;e+�3'. D ->y a o � Cjn� CP n 1. S� N �� �" 7P`n 9r3 S�''3 va x' t•+ Q � ~ O N� � 40 r M Y D a A O O '0 f G rA cs, Z rt IP .yG e O �y va t;j G = ot► •t+ G {fi" C '" CSG vat CD co41 to N„�'q p � co iF7� 0,i a 401 i --1 V4^ Im 14 , t` . . MERCHANDISE NOT RETYRNASLE OAK GROVE MEDICAL CENTER D lmy 1026 OAK GROVE RD.SUITE 4 SURGICAL AND ORT►I�v"C APftamCEs CONCORD,CA 94518(415)671.7771 PLEASE PRINT: fof R 4-?. /zi ,dL H. EREMPLOYED 8Y EPEAT SOLD BY i REO A. 0£R DATE "TTING DATE A NI N �r ELIVE E DEPT ACCT. CODE OTT. OElCRIPTiON PRICE 707 •;,c% 030 SIGNATURE cAax C• 84 r ,. MERCHANDISE NOT RE'TURNASLE OAK GROVE MEDICAL CENTER DELtVEQY 1026 OAK GROVE RD.SUITE 4 suRG'CAL AND ORTHOPEDIC APPLIANCES CONCORD,CA 94518(415)671.7771 PLEASE PRINT: S D Q T R IG/ p. �- dot/y' Ste,,► N EMPLOYED SyCREDIT E A WbTD By ! N FINISH DEPTCOQE QTr. Di/CRIIRION PRICE w linr SIGNATURE H H 84 1b823 PATIENT NAME DIABLO VALLEY RADIOLOGY MED GRP CATHERINE GRAINGER P.O. BOX 5016 SAN RAMON CA 94583 ACCOUNT NUMBER STATEMENT DATE 1072396 11-28-88 fORMARDINC AND ADDRESS 90RIIECTION •CRUEST[O 7640-819 • � AMOUNT PAID Place of Service : NT DIASLO NDSPITAL I/P 27.00 SAMC�10�3072396 CATHERINE GRAINGER 1802 ALICANTE CT DIABLO VALLEY RADIOLOGY MED GRP CONCORD CA 94521 P.O. BOX 5016 SAN RAMON CA 94583 Billing questions? Call : 415/866-8435 PLEASE DETACH AND RETURN TOP PORTION WITH PAYMENT DATE DOCTOR CODE DESCRIPTION AMOUNT 11-05-88 D KAPLAN, 14.D. ,INC 73564.26 KNEE COMPLETE 27.00 OUR OFFICE HOURS ARE FROM - ACCOUNT NUMBER DATE OF STATEMENT AMOUNT PAID PAYMENTS AFTER THIS 1072396 11-28-88 YOUR NEIXXT LL STATEMENT 27.00 PATIENT NAME AN INSURANCE CLAIM fQRM #SAS�`'�{EEN f!,I:1EO HOMEYEFt. MIS BALANCE REMAINS ' ►T N. PLEASE CATHERINE GRAINGER EMIT PAYMENT *DDAY. x t MAKE CNECKS PA9ARLE TO: DIAELO VALLEY .RADIOLQGY DIEDirRP» �k � ��� ox 4 A 3E2ONE i EVIS '!ID .I°MG I C CAUL E'oltRalz '�tl►or AtOMALO A 11E211TRA `ND #PC FO1fAR0 # $Slltfl Ita 3111 *TSN>FIZNp DANIEL !CA P L A N 7111) INC M ti v RICHARD A)&VAL !!D PC Q aA ! Tf M:91B „ IISERT A 11-Li 110 1MI: flIkM11T. R #C RICHARD M lMiA IID �' dt 3y4v'� Wy SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION • _ PATIENT NAME DIABLO VALLEY RADIOLOGY MED GRP CATHERINE GRAINGER P.O. BOX 5016 ACCOUNT NIANBER STATEMENT DATE SAN RAMON CA 94583 1070908 11-28-88 vDA11ARO1NC AND iODRFS'R R;DBEil2.8N REgY£St[0 4A4O-f8! . .. • AMOUNT PAID PIOCO Of Service : NT 0I411LO HOSPITAL I/P 47.00 fANC�10�1070908 CATHERINE GRAINGER 1802 ALICANTE CT DIABLO VALLEY RADIOLOGY MED GRP CONCORD CA 94521 P.O. BOX 5016 SAN RAMON CA 94583 Billing questions? Call : 415/866-8435 PLEASE DETACH AND RETURN TOP PORTION WITH PAYMENT DATE DOCTOR CODE DESCRIPTION 10-29-88 DONALD COMEN. 04.D. 73560.26 KNEE LIMITED 20.00 10-29-88 DONALD COMEN. 14.D. 73564.26 KNEE COMPLETE 27.00 i OUR OFFICE HOURS ARE FROM 9:0 2:00 & 1:010-4L."n ACCOUNT NUMBER DATE OF STATEMENT AMOUNT PAID AMOUNT DUE PAYMENTS W�APPPPEAR ER ON 1070908 11-28-88 YOUR NEXT STATEMENT PATIENT NAME App3NSURANCE 'CLAIl1 f'ORM 'NAS-MEEN �f- EO MOVEVER, .HIS CE REMAINS 4at1A091 IGATtON. PLEASE CATHERINE GRAINGER #IIT VAY0IENT T -DAY HAKE 'CIItCK 'P:ArASI[ TD: DIABLO VALLEY .,-RADIOLOGYD itP k `g`.,! ' 91► r� k L 7ERpNE Lewis '1!0 IMC ° blii y1QRlItA +Ip ► )SeA �0i'p Al , w'; imp' TAL !F #ONALS A `ytINTRAgB IID A�; MAA4 L�SN�S i10 �Mi •tss a e� a OANIEL icA - 11D !MC' D#I``1IID 4 RZCNARO iAvat ND PC `" ;: .x. AD �#2I1D5' C 409ERT A .1•AitK 1:0 A4 �5 �IwIARA�)t sI611RO It siAEL :1�lIliC � Kt i PI a l SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION m W W ? .l�, W {.D. w W lid i • w I - r! nz cc 4 • zl � � � I�. O W F N • E ^� I 4J EUv I w .2 ILLI W N Q as a 't N ►+ N U Z OD 3 F �- iz O ( ttt a :0 r. W M N IOD LL ~. C\i N - J m _ I � u .d Al Q, 1: I L A C U.Im > a w d U W 14 V iLp so ! b4l � zta ixi ;rlAVJbw t — O } V !sx — �— • Jxc. r IWz � \ | � . . ^ . APPROVED OMB wo 0938m79 S PATIENT CONTROL WUNDER WIPATIEN"LAW NAME NO IS TE MR tirm..101 121 IFTATM THROUGH DATE Cii)IMES or AW CD Ali" co CD AW :�]A.UT 00 DESCRIPTION 61 k CODE 52 S.UWTS 43 TOTAL CHARCIES 54 56 W 7_77777 m 3328.00 34. _COMPUTER CONVERSION I HE 4 DX X RAY 320 604.35 OR SERVICES 360 3160.77 : _RESPIRATORY SVC 410 4.61 EMERIGENCY ROONt 450 276.70 12159.19 97 PAYER 6111 DEDUCTIBLE 61 CO4NSUR^MOE 0 EST.rza-ckwoxrry 0 PROP PAYMENTS 04 EST.AMOUNT DUE 85 INSURED 6 NAME 0 CERT.41SN-Ni 10.NO 49 OPIOUP NAME 70 INSURANCE GROUP 40 71 Em 77 EK 74 EMPLOYEE 0. 75 EMPLOYER LOCATION GE SAN FRANCISCO, CA. GN GRAPHICS DESI 2W 111-41501111111 St U XX X NOTIM TO The hospital Is actino solely as an agent for tho patient In filing for Insimum bermfils THE PATIENT sai lo It however,the hospital can assume no respoi for guaranteeing payment a]amrad cherome as slow on the face of the bill.Credit Is shown only when the hospital has actually received paynmmL Should an overpayment be made,a efu. W will be .sant to the authodzed party OW Is due the overpayment. UB'82 HCFA'1w50 PATIENT COPY Ar MT Ti lABLED H5 MEV 'ENTER.- (P-GE No. BCCA. 44`61 OF F�8 I ut DATE OF BILL 'D SAN FRANC1S=1-S-- o A. 94144 415 .6 7 A-' �z 10 Z MT." DIABLO HOSPITAL MEDICAL CENTER lo 2540 EAST ST. CONCORD,CALIF.94520 OPERATED BY THE MT.DIABLO HOSPITAL DISTRICT L 8 PATIENT NAME f PATIENT NUMBER ISEX T_ ADF.5;551oN DATE I DISCHARGE DATE DAYS Al,I N ri U r: , ?.;A T H;:R,I N�. INSURANCE COMPANY GROUP Isla.- L 1 ir.I t,�C 17�' 101 5 6`6 06 1802 AL.I CANT;_7 C-i N'u"T'l I NGHPill P MD -DETACH HERE AND RETURN TOP PORTION WITH YOUR REMITTANCE TO,INSURE PROPER CREDIT -A ATE OF DESCRIPTION OF SERVICE TOTAL EST. COVERAGE EST. COVERAGE EST. COVERAGE EST. COVERAGE !ST;MATEE, PA_-;FNf' ERVICE HOSPITAL SERVICES CODE _._CHARGES INS CO. NO. 1 INS. CO. NO, 2 INS. CO. NO. 3 INS. CO. NO, 4 AMOUNT T C A V I, I lTS 13:_, 70 L'. '7,1 C' 7,-i III A T I r.1` 1- HV,Lr' H,P.L' 4 10 ZLI C),Ij 17 TOU I 0 0J F I R 1- H R*!-.,'- 4,7- 1 1 t-�. 0` -71 IF I0. 00 C 7D- 9' I-1 7 0,F I L ' �7 P7 IRHO!", A11111z:: 4 4 Q 0 1")C151 .2:0 155 . 20 c0 r-DTL ../2' 4400fl_)C.)5 301. 701 30)1 . 70 (7W*.-.11p � .- :>r'.. ll:�'�='SETTE 10 600B I 1:� 20. 94 LI 94 ,,F Ar'r 6 4 6C)17100 51 4. 56 50 7, 0 P A F, SIOHE 4605301 10. 11 !,C. 11 tl, C;:*,J NASAL 460611150 A. 76 4. 76 CAT! ' I JELCO 4608350 6. 66 6.66 PR`TH 0 4609650 14. 97 14.97 Cik.:I EGk ,_7 IODAN 66 461_53- 2(d 31. 64 3 64 001 rl F<A r�'E C ARMARM �X2 4613729 19,'86 19.66 0th ro r.-P._7 TOWIEL 10 4613750 18. 34 10. 3? CC)I EiRSrvL,_' X F_F:0 5 X 4 6 143 0C) 3 5 :j.9C 001 IV ST W!0 46175,60 3. 821 3.e2 ('01KIT AD !',.SSION 461765: 10. 34 10.34 7.., 01r*r -_R R_ r"IT PIAT!. EFF* 4 6 17 1? 2.83 .4a.e3 111 it T -�45 P:P S-"C' Z 0 t�61 SL 7. 77 7. 77 001WIT LTA 4618 1 12. i4 12. 14 001 MASL' AN!"S OHIO 4618450 12.5e 12.58 001 F M I NIOR, 461925"") 9. 92 9.92 ;D,- V 003PACK Ga 0 t;!r-It 4619","t 11 . 0I i c", 00 1 PACV, EX-f P E N 1 T Y 4619'?rt:5 1,-, c 2 004PAD!'0z CAST P,;; 4620 14. Y2 i 00JPAri 1:'Et--/EGC-,* CR' 4621 5 C) 0/:'.`l9 001 PAD PRET 462'1 5 3. 69 3. 69 I PATIENT NUMBER PAIIE I AMOUNT IS DU! WITHIN 10 DAYS OF THI� t74lE1.•tNl DATE. ADDII!ONAL PAlItN1 BILLING MAY BE REQUIRED BECAUSE OF CHARGES REFERRi5 10 liE SUSINV5 OFFICE AFTif? THIS P:Lt WAS PREPARED ORSECAUSE INSURANCE COVERAGE DIfFEREL)FROf.' OUF FSTIMATf. PLEASE RETAIN THIS STATEMENT FOR INCOME TAX PURPOSES HCS- FED. TAX NO. 9A-6003847W PATHOLOGISTS RADIOLOGISTS NEPHROLOGISTS ELECTRONYSTAGRAPHY FOR LABORATORY SERVICE DESCRIPTION PROCEEDED BY A LETTER, SEE R. HUNT M.0 Di?EIO ,A:L[y R. VERTAL M-0 J, HARRIS.M,D. REVERSE SIDE OF BILL FOR IDENTIFICATION OF REFERENCE LABS. M A6:I M.r, RA)i,:)IOGr MEDICAL GROUP 1. WEISS, M D. 0 TROYI; M.D RADIATION ONCOLOGY V FANG, M.0 ELECTROMYOGRAPHY D slERL44 t L� R CARMEL MD R. SEIBEN M.D MT 1?IFcciL.0 HD-=F MED CENT F: PATE of F'.O. BOX 44:.61 'E OF BILL DATE OF BILL PaF<' au: SAN F"RANC.ISC'7, Cci. 941.44 L:LE. 1�;;31 .l8 ! '415 674-- 1U2, MT. DIABLO HOSPITAL MEDICAL CENTER 2510 EAST ST.CONCORD,CALIF.91520 6"' OPERATED BY THE MT. DIABLO HOSPITAL DISTRICT PATIENT NAME PATIENT NUMBER SEX ADMISSION DATE DISCHARGE DATE DAYS 106-"'64!:14 .1 3:=: 1�,,';?�'/rsC INSURANCE COMPANY GROUP NO. I-IWAU. . %;•__•IFAINI"` Iii 526566arc-660=5 180:_ FALTCANTE C l- F HILI DETACH HERE AND RETURN TOPPORTION L • ATE OF DESCRIPTION OF SERVICE TOTAL EST. COVERAGE EST, COVERAGE EST. COVERAGE EST. COVERAGE ESTIMATED PATTE, • ERVICE HOSPITAL SERVICES CODE CHARGES INS CO. NO. I INS. CO. NO. 2 INS, CO. NO, 3 INS, CO. NO. 4 AMOUNT E-I I F, SL. est"r:. L'. T !�1-_,:i� 1_+_ �._ ��__ T-c -Tc = F'K. 462 b z t>' l:,t- "t T H E'.' :"7^"` 77 F F. C c; ri 6.'7° (iC ._T LIF_ `r};.c:E:i_:T .� !�._-7. ": 0' !TUB x'-.11'-.�:CL:!- r-r�,.51=i ✓,_ t-., �if-� u, 91; _ :l F�•..TUL'• J.!' .r;'•. ... 1'TC''Ja. _x+:_ �>t ♦±.�� 6. bJ is t:i Uy'•_ c_:, F'K 46.3 5L:: 4. 1-- S, . 13 F% 46 3 t. 4. 1? :,. 13 "!R !;-H;--Cs _ RR463'.'c:il? 5. (-4 5.04 ?aHI_... I F;.:.:1 E_ 1 C.!. 465 0'.'5 --.95 4• F'F:0X F'S 466.581 5'2. 7-21 52. 3 (IL:; LCOP.?' STF:Y 4687t::95 44.94 44.94 `,. F NP1fizN F 4687895 4 8. 36 40.36 C3 F•LPi t•:t�.il ASI 4687"17 �9. 9, �2 !I .i'I L.A T r I ;-_ Ac-:IF 4687Ci-=1 233.r 1 71 (I ).1c.CF'.'._ Cr;TZEL A 4688ii46, 157.3 !=GTSCR' r_' ;;TEx A 4•-5E3R;i47 1 '.z?. 94 7 -:'=._. 94 _ !':;�.SUTI. �: �• ATR PY 468B-364 : r t: ,::163 L 0 I_I TE RK 46E8K59 7.63 7. 63 CI of PEI ! e^'' E Vi_Y 4695122 6. 15 6. 15 =`Ly r!(:)-SUI :3E:,l A?F: 4691 S,-44 31.04 31.04 _ 0 Ur,.I :'= Li-S 1 L AT? ::021 i1C,5 14. 6-3 14.63 S,0 3O2It%}5 1_1.5= 1=1.5,7' ;:9 001U1.FVE:.tiSi•47 IHi_ 5035??1Q 16. 85 16.85 001 HEM-D lam: 1 5t:i35t:-!` 20. � 2--'.25 001 HES"f}.l =4', :jti3�i'•`i` I r: _ '2` t 2'r` POTASSI.1r 1=+i4!:' 4� 47 47 rel>iF'Ol �"SI!_. . C:i.4I . . 2 -. 4' 4? JOD 1_(ji`l �.5�1 4"9 a-«... 4 i._._e 4- (? �C ) G' 2.U. 09 PATIENT NUMBER PANE NT AMOUNT 15 DUE WITHIN 10 DAYS OF THI_ STATE,.sENT DATE. ADDi T)ONA: PATIENT BILLING MAI' BE REOU IRED BECAUSE OF CHAP'- REFERREC TO TwE BUS,NESS OFFICE AFTER THIS Bill WAS PREPARED OR BECAUSE INSURANCE COVERAGE DIFFERED FROV,OUR F57!,AATF PLEASE RETAIN THIS STATEMENT FOR INCOME TAX PURP05F S HOSP. FED, TAX NO. 9a 6003BA7W PATHOLOGISTS RADIOLOGISTS NEPHROLOGISTS ELECTRONYSTAGRAPHY FOR LABORATORY SERVICE DESCRIPTION PROCEEDED BY A LETTER, SEE F HUN;T M D DIABtO VALLEY R VERTAL M.D J HARRi5 M.D. REVERSE SIDE OF BILL FOR IDENTIFICATION OF REFERENCE LABS. M AF,.E MD RADIOIOGY MEDICAL GROUP T WEISS M.D D TR�XtL MD RADIATION ONCOLOGY P. FANG M.D' ELECTROMYOGRAPHY D Bf EF:U1JE MD R. CARMEL M.D R. SEIBEN. M.D. PIT DIABLO HOSP t Er CENTEr: PAGE NO DA-F OF F'= O: BOX 44261 E OF Blll DATE OF BILL FRE, 91u SAN FRANCISC.r, CA, 943 j 'LF1:0/3 E. 415 674-2:102 MT. DIABLO HOSPITAL MEDICAL CENTER 2510 EAST ST.CONCORD,CALIF.F.14520 6 7 OPERATED BY THE MT.DIABLO HOSPITAL DISTRICT S PATIENT NAME PATIENT NUMBER ISEXI I ADMISSION DATE DISCHARGE DATE DAYS A l i.6i R LATrG:=.F:I IJS l j✓6�640E=fes i 3 1 O ioS GUARANTOR INSURANCE COMPANY G OUP DAPJ: EL C:,RA 1^:CEF: I01 526163 18012 AL.I CANS I E CT CONCORD-, CA 94521 N-OTT I NSHAM P Mil ANT I rqm F 1 TOP PORTION . ATE OF DESCRIPTION OF SERVICE TOTAL EST. COVERAGE EST.COVERAGE EST. COVERAGE EST. COVERAGE E5TlMAT-' PATI_ RVICE HOSPITAL SERVICES CODE CHARGES INS. CO. NO. 1 INS. CO. NO. 2 INS CO. NO. 3 INS. CO. NO. 4 AMOUNT (_I I_ -.TAT r.J'l LTi r•C i}I_>S. .%i r._„ ..� �..._ _E�'� _ j �.I��y 1•� 'i J:^i c� E_I Jt'. /Cf•��:'•C C. �'a _ I. a �•1 .:. i C':i.ME E X.Tr; i7' D S-. . lc70... . i?•>_'. _ •J 1_S�, ii;i 1.' jIE_-�i�_. fi._�l�C.r `•.moi 1 .. � - 1S4a '._{^ iF'itI. .�. EUc:, 1:7. gt. 6E . 1� la::,i! f.IG C,CI;<r'�F:': _•37�4:-. 14: �•] 1 1 ^.. L 1 _ SIO�i'� r. . r tii'-�r_ -E `�37� 114. i 1 3 . _ 61 E.. �•l!`";r.`E.-r` 637 `_�i i i4. v3 11 4 ETU 7:.. r',1 , 6399;i66 60. 26E�IF J _ LET- _;.� -1 !1-74- 1=_ �� 1 ; .204 �.'. 1rT�h:' e ii:: . SO4 1 7CFf'13 ??� 1U. 5_ 1{: . 5.1 74070-8 3':. 25 32.25 : G'. _LIE X. 5 'W!ATER 7007(;34 10. 3101 _0 _ E •: :F0Cl ..�? 10i -,1:11 416. 00, 416, 0C) • ('c 1"{�r•• .'•_'fel 5035Q 15 �FO1 E;_- 1 ._. , 70004 � 14 .AF0 ��. A4- 2". 47 _IL.i PR 1 G ((100rT36 2:-E a 30 -71 r E.Ft;Z C:!-d FE i r 'TOT?ut;36 26.31:1 _. 30 'tiYElT::O; 10OMr 700+1285 29.46 29. 46 :;_;r.'C;7c7':?C.'_.C1.'FAM 10 7041 ,F1 38.40 38.40 `'_•:":' C,C) IT R I Z SLF 4,- Q a 25./ >�,c��r=�1 4.36 4.36 _. _j:LEL�. ^. ;4.�'.1' j 1• ,T:y:1/:'L7 i• i�L 60 ~,',1 t 61/) _LIEX 7007073 20. &..-) L^.60 {c, oci i F�000-l: 422. :>100001 416.00 416.00 O01 R00':" ��. =1 nC,1.. _:1 416. 00 416. 40 FORT AFZ-1 1" C_E 'i s; L _ 7664. =rS 706-: . 9D PATIENT NUMBER PATIENT AMOUI:T IS DU[ W'.THIN 10 DAYS OF TH 51 ATF N:E NT DATE ADDITIO 4; PATIENT BILLING MAY BE REQUIRE[' BECAUSE .OF CHARGES REFERRED 10 THE BUSINESS OFFICE AFTER THI; BILL WAS r ^ r G•4�1'�?J� PREPARED OR BECAUSE INSURANCE COVERAGE DIFFERED FROM OUR ESTIMATE. F'AY THIS AMC}:_:`vT 0. CIU PLEASE RETAIN THIS STATEMENT FOR INCOME TAX PURPOSE5. G.P. FED. TAX NO. 94.0003647W PATHOLOGISTS RADIOS OGISTS - NEPHROLOGISTS ELECTRONYSTAGRAPHY �R LAE�DR�R>3B`F_QERV7L IDESaE7$11IIOg�R ED BY A LETTER, SEEP. HUNT M D DIABLO VALLEY R. VERTAL M.D J. HARRIS,M.D. E1J R,�F S pE PpP1+' F. IDENPFACATION OF REFERENCE LABS. M ABI F. FJ..D RAD O.OGY 4•.ECICA; GPOUF T. WEISS M D � i''I`' D. TRO-F: MD RADIATION ONCOLOGY P. FANG. M.D ELECT2OMYOGRAPHY D BEER;INF MD R CARMEL. M.D R SEIBEN.M.D. MI IiIfi'B' -C ME-D CE1 T� -F: PAGE NO. • ?A,E �1 F. Q. BU"� 44-----'i'E JF BIL!. .CITE OF BILL F\' 61:L SAN! FRi ME"I f-'r'V, (-'P. 94144 yr LE 1::',!3'- 8l:L--j 415 67/ 4-2'102' MT. DIABLO HOSPITAL MEDICAL CENTER_ I' 2540 EAST ST. CONCORD,CALIF. 94520 -' OPERATED BY THE MT. DIABLO HOSPITAL DISTRICT PATIENT NAME PATIENT NUMBERISEXI ADMISSION DATE DISCHARGE DATE DAYS P.I r-4 IM -^; 1062640-' 5 1 ( 3.' 1 Cl; l ' 30 GUARANTOR INSURANCE COMPANY GROUP NO.--! UAr•1= EL :F:A r<=EF, I01 526568 11 A11!._ E CT r•sl;TT I PZHAIII F' tierI DETACH HERE AND RETURN TOPPORTION 1' TO INSURE PROPER CREDIT 5,TE OF DESCRIPTION OF SERVICE TOTAL EST. COVERAGE EST. COVERAGE EST. COVERAGE EST. COVERAGE ESTIMATED PATIENT :RVICE HOSPITAL SERVICES CODE CHARGES INS. CO. NO. I INS CO. NO. 2 INS. CO. NO 3 INS. CO. NO. 4 AMOUNT 0 F7 :� .' i., —F'tti ?It�.�T'G C �4�.. Cir_L ;tom CQ'='F_F-Il C)4C �:c''=. . ' -t met_.. 9•' F;i1ES cJF'i 64(-)-l- 452. y`._.. 9C. .. , 361: 17 3544. 67 3``;. 6;' I-;ES:'=' Tris_.;•, 4 J 141`x:.' 4. 61 4. 61 FPiEF, F:rli1;' A2 C!443C1 135. 7") 13u. 70 E_,; F': I f-!1 44 10 138. 0'.. i 3t3. 00 �....z .i Cl':-- rt.i;:.F:. CHAF03ES 7664.98 7864. 9S FO _. LAI' TEEM S G1I TH lt-IL"LUIC '.€17. 5 LAI; SERVICE CHAF':'GE 0 T r'i L i► 7E?-,4. 96 721,4, 9E' PATIENT NUMBER PATIENT AMOUNT IS DUE WITHIN IC DAYS OF THIS STATEMENT DATE, ADDiTLONAL PA71FNT BILLING N.AY BF REQL" 0 BECAUSE OF CHARGES REFERRED TO THE BUSINESS OFFICE AFTFF THIS fill: WAS PR EPARFDORBECAUSE INSURANCE COVERAGE DIFFEREUFPOMOUR ESTIMATt. PAY THI v, !•^,EMI' !'.1�' may(; PLEASE RETAIN THIS STATEMENT FOR INCOME TAX PURPOSES. JSP. FED. TAX NO. 9a-6003647W PATHOLOGISTS RADIOLOGISTS NEPHROLOGISTS ELECTRONYSTAGRAPHY )X AFDt4l6By(3E0-VIM..IDE SeISMOg l!ROC$E D BY A LETTER, SEE R. HUNT MD Di C) "Ai LF\ R. VE RTAL M.D. 1. HARRIS.M.D. = iEE S�D�,Qfi_ L``fOR•..� NjJ.W. TION OF REFERENCE LABS. M ABLE M.D PADIOlO-+ N.LDI:AL GROUP T. WE•SS. M.D. 'rl•: j _ -FiD 7ROXEL M.D RADIATION ONCOLOGY P. FANG. M.D. ELECTROMYOGRAPHY D. BEEFLINE M.D. R. CARE[,, M.D R. SEBEN.M.D. M -D "L EASI DETACH AT PER f OR AT ION AND RE I URN V.'l I H YOUR l'- - CAL CKIA VEF-e PAGE 4 FAMOUNT ENCLOSED TYP�E , raric I CA q4 1 4,1 FINAL IN F, PATIENT NAME PATIENT ACCOUNT NO. ADMISSION DATE I DISCHARGE DATE, BILLING DATE G'RzG jWn[-.l-,, CATt IFR'l NE 40A E� � 0/29/8E: GUARANTOR INSURANCE COVERAGE POLICY NUMBER GRAINGEIRiDAN' ci METROF-L-ILITAN LIFE 1G:"').- ALICANTE C.f0J;-%.-i C:0N',"--"SIN-:IJ CA, 94`' 1 SERVICE DATE SVC.CODE DESCRIPTION CPT CODE OTY AMOUNT C ID N V i iR I f.i Z-AL A'N Ct;- F 0 R W.A R 1 7864.9E, SEMI F;iIV 5 �I)S o CI PH;A F"In�c-L,Y 79. 5 1)R U G-,• I'A K Erik SNL 8.65 5 1:39 15.78 r;lAG I 1 114.(: 1 F1 i Y S T H L R V I S 3 T 1 .11).4',: m ".-,l.A.E(LCi ME-DICAL C:EN7Ei-,, L f1t I ASI.DL I AGH AT PERFORATION AND RE-TURNWI I H YOUR HEM IT TANCE PAGE C'. ;J3 o x 4-} 1 rAMOUNT ENCLOSED F'r aLr.,c i s cc, i CA 9.1 144 TYPE FINAL I N P I 2ATIENT NAME PATIENT ACCOUNT NO. ADMISSION DATE DISCHARGE DATE! BILLING DATE 9 E! 1 /0, 111/Z 0 GI-%'A 1 NIQFI-11, CATHER NC c4f--W-r �C '� 3UARANTOR i INSURANCE COVERAGE POLICY NUMBER GRA.T NriER9 DAti IFL LIFE 5.=r `.&S-I='-o E.,/f:,.5 ALICANI E C-OuRl CIDNCID't D CA 945c-:j SERVICE DATE SVC.CODE DESCRIPTION CPT CODE OTY AMOUNT i0A; R 7i10i 4 Z 0! 1 .97 N(.k-*F1'i CAT '(C'17 MILK Cir K;VGNESIA G3;A I N G El ;.:A7 J 7 0 0` DIA-7cpAm, tf""'-) clf-�-AL I Q ;Gf'�A I WjEl-N'i I 7 1 *-:'f"E*F(1.01M... INJ CON:l I ML. I 00MG 4 41 .0r' Cii"'A I NGF.1 -,-":-ik7 r"L-I-." :C'DAN Lit •A I Ni6cj` A 1' 17 4.24 hi 1 2 0.0 93 C:Al.. TI 1EP lF rPAD "M PK. 'SM UNL 4c,: 4, 1'! 4 E C) UN D�T'%'F A E) PK/SM 4 1 ","I MIC-_'CI-Sw I U SF 1,112 F,('%- R lCIPI 4 1 41&,.00 8:- &50(i 1 -78 A S 1 S'J'A NT 1 17 4_; err! 70 6. 7C - 7 R" LDLAM lltMC:t C:A` 0;1*�: 1 i;0`= '� '.i �, ;' 70, ;G'r"'A I N G E 708 -,L-C7E114.6 7- CIPAN 0QAL DIA_ 6-51 :7 C 1/ 7 t: 4 6 MEi*'l,-7.:--lu11,J'-'-' INj 4 41 .0C F-.'A'a N G.Fl a C:A T T .:r-: ;GkAlWo CA7 16.50 I I t., t".7'j Vl,-:ODIW, Uig GRA 1 N(:if-P i `:AT 4 8.174. 1 30.00 3 PHYSICAL YHE'R MSC 4 6. 11 4 -Vr,j 'sori 5 -E�:7 2 C.)0 4 SUR'', SL- mi 99 850-DtiO 15 GAIT E"X F F,C:I S C 5 131 . 10 700 Z' 13 TRlAZC-'lLA14 0.Z!'5JMI^.:z -'GiF-.'AlNGC7.R,'iC:A"l 1 2-. I e 117 0 ;,:3:-:3 1 FmE I P'r 1 oris ;GRAINGERj'A T I E.65 3 1 0!:" 700 :6v9 VIC00IN UF! ;GRA IN,%'CRqCAl 4 8.9 12-1 C;. THER MSC: -40.00 1 /t76/8,-, 85999993 rPHYS I CAL 1 FLS I I I &D 7(")01;:`:083 HE,, LOCI:, ;li i-ZA I N GK R,9 C A T I I i:j7/8:: 7()0i,6f::1 I MFT'l_-IC:Lf-.iPRAt"l 10INJ -4 -3G.4C) GRA I NGF*R i CAT I /E<E3 7t')0 2:'7':13 TRIAZOLA11 O.ZtM& ;GRA INGERiCTAT .2 4 1.*:'- J I W*,".1 85002:400 , EVALUATION AND PLAN 1 -Z6.ZZ H1 0 4 Q 4 5 TOTAL NDICATE AMOUNT ENCLOSED AND RETURN 70P PORTION WITH YOUR REMRUNCE. TOTAL CREDITS INCLUDE PATIENT ACCOUNT NUMBER ON YOUR CHECK. TML DUE RETAIN BOTTOM PORTION FOR YOUR RECORDS. ESTIMATED INSURANCE COVERAGE HOSP.FED.TAX NO.944=W )R LABORATORY SERVICE DESCRIPTION PROCEEDED BY A LETTER,SEE WATED PATIENI =VERSE SIDE OF BILL FOR IDENTIFICATION OF REFERENCE LASS. F'LLASL DETACH AT PERFORATION ANDREI URN WITH YOUR RE MlTIANCE :CAL CEN t'E t4 1v; ;:;'X 44:'- 1 PAGE - �,.. F [ c. t CA c4 1. .1 AMOUNT ENCLOSED TYPE I FINAL li I INP J ATIENT NAME PATIENT ACCOUNT NO. ADMISSION DATE DISCHARGE, DATE BILLING DATE � II P"•:' µ 1 /l)I:•/L%`_ .. 1J�t_)j}_ %;rt�C t f.-F hJI=" �•I I � •�~• �: . mac• :UARANTOR INSURANCE COVERAGE POLICY NUMBER Gi<ri iNGFR UAIv:.Ll.. f> ETF1CiP-0+-.7 TArq LIFE 5z6Ez :ir,!.;5,/r_•5'�7c:' 1 :+' ALIGAN-Tr: C:CAJ! i- C:CINi:;I.I)',,I) CA Vi=i -_.'• I I I �I SERVICE DATE SVC.CODE DESCRIPTION CPT CODE (7TY AMOUNT 1 f., i? ."_ . �:r�ci•:;�7�;t;=: F'tiY'_. %AL. THEE' Mac.. F=itY ! CAL. Tt-iER f+:�i' 1 t. �..'o::i I :=r;�7;:,:%•'Li??=:I F+] .�:i-'tai;•:ni..i r Z TT I N':_ � T: •i_'r:- I 1 i,!t. _ . 't.'('•(:°:�+.1J� 17T 1:$. 1'Yi_ 'i:"j .t✓� I)—ft.' 'F I i ... 5 { .. (J� _ . �:' .'.I �.ry•_ t1 Ca` ...1_Il�!'', f' 1(.� _U i 1 :±:,i_..- I 1is0i�11= ! 61 .d_• �� - - . .. [-`• ! 7'•_)(3 '. �Ca�[) I'�`! .FNi W . 0 r _ :tt f�c' i Fy,�,;_ ; C i,L. THFF: f+iEEC 1 •]t�.O( t.iiv))` !••t <'.I? Jt' vrtj 1 4. 1•_ 1 tom . =]': �.1 Cj'•:;i?;:;C 1 MCI r- ,:U /`3r--M I Ph i F.+: t]hi � � 1 416.00, 2 <. . }i.!i7(_j. ')— /;"'ir'1 PR ;F,:).(:IM 42._ 1 41f,,00 :TT)NG1 /_•. G- 1' T i{t,I r-4 3 i.ti', - 5.::.44 I :.iNA_. RA N& 5,=.4'! I 1 . ,,.,:. _ . 7(;[_15 J4,�_• ME.:-'E'�I1'•1NE, I N 11 10C MI..[= I 4 41 .t?:_ ;G�4,11NGER', A '7 _ i.`•: _ . _ : 7t�('�i It,:;A T 1 T't'i.' :i tJU ;GPAIN:]ERYCAT 4 - " :I �::.,_ i E i,L FtER Irt C I 1 :10.C)Cl � 1 _ �J•. J.J. .' •. i F-'F' T L.. 1 i .'I:' %+.') }]'.,;'(:._'^•!� F_+,i)1f' Int:_N') r ITT1WG 1 H AND PLAN I 2!=•.._� c.F30r)_,;r_: GAIT 7i .A.3t•I .;iG 5-.44 C;(?c:;_; [?C r'UNC:I-I ONAi_ TRA.F r,)I hd ; z 5;7.44 ? i:''•: _ , _ . r(i(j:]';-ii_= F'UNC !'I)*.NA,. TRA INIWi -5'2*.44 EtDi.S I'r'ntL:N'i- FITTING 1 - i.•. GAIT Tf;A3N? NG —5-.44 1 1.':.:_ .''_ 'i'[?':�'='�. �1ti CL1�1 ! /I':1 1'i F' 1.'—" 1 4 .-..� r .t. i i.'c: ^': 46,.>F�C fG r kEh1=+V`E;; :=,? �:r LE 1 10.Z5 4F,O;:?!..0:3 CLI-` 4. li:`;:)-;!c:;:: 21(?t)c:x:'-1 ME!)- :Ui;/SE`"!i PR ;R00re, 4-;': 1 41� .00' 111(:'q r S!00: ::'CY FUN, :TI;:)NA.- TRAINING 1 Z6. z 5-.44 1" (Stee) H.106-'-!-4 045 TOTAL INDICATE AMOUNT ENCLOSED AND RETURN TOP PORTION WITH YOUR REMITTANCE. TOTAL CREDITS INCLUDE PATIENT ACCOUNT NUMBER ON YOUR CHECK. TOTAL DUE RETAIN BOTTOM PORTION FOR YOUR RECORDS. ESTIMATED INSURANCE COVERAGE HOSP.FED.TAX NO.04-6009847 OR LABORATORY SERVICE DESCRIPTION PROCEEDED BY A LETTER,SEE ESTIMATED PAIIENT DUE ;EVERSE SIDE OF BILL FOR IDENTIFICATION OF REFERENCE LABS. n' �I AELC! ,nED1CAL CEW'i'EK °,�ux 4PAGE Franciso . CA 94144 AMOUNT ENCLOSED TYPEI NR / � WIENT NAME PATIENT ACCOUNT NO. ADMISSION DATE D111 CHARGE DATE B�LLINGDATE 3UARANTOR INSURANCE COVERAGE POLICY NUMBER SERVICE DATE SVC,CODE DESCRIPTION CPT CODE crry AMOUNT lNj 4 7f - �� PHYSICAL. THER MSr_ 3c; 00 TOTAL INoICKrE AMOUNT ENCLOSED AND RETURN TOP.PORTION WITH YOUR nsMn1ANoe. TOTAL CREDITS INCLUDE PATIENT xccbuwrNUMBER owYOUR CHECK. TOTAL DUE RETAIN BOTTOM PORTION FOR YOUR RECORDS. ESTIMATED INSURANCE COVERAGE #40SP.FED.TAX NO.94-60038w onmBonxrOnvSERVICE DESCRIPTION PROCEEDED evxLETTER,SEE ESI IMAI ED PATIENT EVEnSE SIDE mpBILL FOR IDENTIFICATION mpREFERENCE LASS. CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is yd rynon J 9 9 California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $878 . 68 Section 913 and 915.4. Please note all "Warnings". County Counsel CLAIMANT: WILLIE L, THOMPSON 3201 Florida Ave, JA(q 2 ( 1989 ATTORNEY: Richmond, CA 9L_804 Date received Martinez, CA 94553 ADDRESS: BY DELIVERY TO CLERK ON January 24:` 1989 Risk 11anao-e BY MAIL POSTMARKED: January 19, 19.89 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PHIL BATCHELOR, Clerk DATED: January 27 , 1989 BY: Deputy L Hall II. FROM: County Counsel TO: Clerk of the Board of Supervisors (V/) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: ( BY: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. FEB 2 8 1989 .11117, Dated: PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: MAR 2 1989 BY: PHIL BATCHELOR by W, 9Z���Deputy Clerk CC: County Counsel County Administrator i Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt'. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County, Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By 11 Reserved for er s st E1E I V E Against the County of Contra Costa ) or ) JAN 24 lAt 0 6: � e c�57 k District) Fill in name Bv .. The undersigned claimant hereby makes claim against the Coun a or the above-named District in the sum of $ ']$o (, $ and in support of this claim re resents as follows: ; - ---------------------------------- ��-------1 - j-------------------------- 1. When did the damage or injury occur? (Give exact date and hour) ----- �� �l �C ------------ -------------------------- 2. Where did the damage or injury occur? (Include city and county) Toe-rnlwoIC, 1"R StA-Kca rod o#kd )11/d. f� R A i N � the K i.d.e at Mir C �K4 3. How did the damage or injury occur? (Give full details; use extra paper if required) _______________________________ 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? (over) VOID AFTER 30 DAYS • SPtLENDORIJYSAUM.BODY & PAINT REPAIR- 1,60 EPAIR- 1,60-23RD ST. ESTIMATE • P.O. SOX-486,STA.A RICHMOND, CA 94MB PHONE'23"793 Date A 7 Car Owner f L7n' Address Home Phone 7 Make �9t Year License No, Type (.! ✓J Mileage Business Phone I.D. - _Adjuster Phone Insurance Co. Inspector' Labor Labor labor Symbol Hours PARTS v Symbol Hours PARTS Symbol Hours PARTS Bumper Fender Front Fender, Front Bumper Brkt. Fender Shield Fender Shield Fender Mldg. Fender Mldg. Headlamp Bumper Gd. Headlamp Headlamp Door Frt. System Headlamp Door Sealed Beam Frame Sealed Beam Cowl Cross Member Cowl Door, Front A.Poor, Front ! -A, Door Hinge Wheel Door Hin a. _. ! r Door Glass Hub Cap Door Glass '. 'I Vent Glass Hub 8 Drum Vent Glass k 'r Door Mldg. Knuckle Door Mldgs. Door Handle Knuckle Sup. Door Handle Center Post Lr. Cont. Arm-Shaft Center Post Door, Rear License Frame-Brkt. Door, Rear Door Glass Up. Cont. Arm-Shaft Door Glass Door Mldg. Shock Door Mldg. Rocker Panel Windshield Rocker Panel Rocker Mldg. Rocker Mldg. Sill Plate Tie Rod Sill Plate Floor Steering Gear Floor Frame Steering Wheel Frame Dog Leg Horn Ring Dog Leg Quar. Panel Gravel Shield Quar. Panel Quar. Mldg. Park. Light Quar. Mldg. Quar. Glass Grille Quar. Glass Fender, Rear Fender, Rear Fender Mldg. Fender Mldg. Fender Pad Fender Pad Mirror Inst. Panel -. Horn Bumper Front Seat Baffle, Side Bumper Rail Front Seat Adj. Baffle, Lower Bumper Brkt. Trim Baffle, Upper Bumper Gd. Headlining Lock Plate, Lr. Gravel Shield Top Lock Plate, Up. Lower Panel Tire Hood Top Floor Tube Hood Hinge Trunk Lid Battery Hood Midg. Trunk LockP int ' Ornament Trunk Handle Undercoat Rad. Sup. Tail Light Polish Rad. Core Tail Pipe Misc. :Materials Radio Antenna Gas Tank Rad. Hoses Frame Fan Blade Wheel AUTHORIZATION FOR REPAIRS Fan Belt Hub 8 Drum You are hereby authorized to make the above Water Pump Back Up Light specified repairs. Motor Mts. License Frame—Brkt. Signed J Parts $ Wrecker Service—$ A-ALIGN WNEW OH-OVERHAUL 5-5TRAIGHTEN OR REPAIR EX-EXCHANGE RC-RECHROME U-FOR USED PARTS EI-REBUILT Tax $ t This estimate is based on lowest possible cost consistent with quality work, and as such, is Sublet $ ! guaranteed. Items not covered by this estimate or hidden will be additional. $ TOTAL $ REMI-3 f Q STO"E OF CALIKSRNIA TRAFFIC COLLISION ,REPORT PAGE,/ OF - SPECIAL CON6TIONS NUMBER . HIT 6 RUN CITY JUDICIAL DISTRICT NUMBER - • INJU ED FELONY ❑ 1x/u NULIMB D HIT MIS SRUN COUNTY REPORTING DISTRICT BEAT COLLISION OCCURRED ON MO. DAY YEAR TIME(2400) NCIC• I OFRCER I.D. Z /'4'v 7----��- f l ° ?// ? p MILEPOST INFORMATION DAY OF WEEK TOW AWAY PHOTOGRAPHS BY: F a FFETIMIES CF MILEPOST SM T plv T F S [I YES Z NO u CLJ 0 - CI AT INTERSECTION WITH STATE HINT REL OR:�Q.� FEETPM*ES l' OF /?d/,f-p a YES No NONE PARTY DRIVER'S LICENSE NUMBER STATE CLASS SAFETY VEK YA. MAKE/MODEL/COLOR LICENSENUMBER STATE EO P. .4 O3-� / cam '. 'e f' /`9/(,,p . T. ._, .�t-N?` . � -� �. . DRIVER NAME(FIRST,MIDDLE,LAST) "-->< 7-& a fry EDES STREET ADDR OWNER'S NAME ❑ SAME AS DRIVER TRIAN PARKED CITY/STATE/ZIP OWNER'S ADDRESS ❑ SAME AS DRIVER VEHICLE 13 f-1flv BICY- SEXHAIR EYES HEIGHT WEIGHT BIRTHDATE RACE DISPOSITION OF VEHICLE ON OR EAS OF E]OFFICERDRIVER ❑OTHER DUSTMO. DAY • YEAR OTHER HOME PHONE. BUSINESS PHONE PRIOR MECHANICAL DEFECTS: NONE APPARENT REFER TO NARRATIVE ❑ ❑ �`���� VC.PEHICUSE ONLY LE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICYNUMBER • MINOR ,re-r-/4- /wf"vt;,• % MOMNN.NE MAJOR TOTAL DIR.OF ION STREET OR HIGHWAY SPEED PCF ICC ❑ TRAVEL LIMIT L PUC ❑ Y 61Afy S~ N� -..PWT'✓ &1 CMP ❑ jo PARTY DRIVER'S LICENSE NUMBER STATE CUSS SAFETY VLK YR. MAKE/MODEL:COLOR LICENSE NUMBER STATE 2 IV or 4f �02 T EO DRIVER NAME(FIRST,MIDDLE,LAST) PED S STREET ADDRESS —.- OWNER'S NAMEAME AS DRIVER TRIAN ❑ 3a 01 eo � PARKED CRY/STATE I ZIP OWNER'S ADDRESS Z/ SAME AS DRIVER VEHICLE V—A` BICY- SEX HAIR ES HEIGHT WEIGHT BIRTHDATE RACE DISPOSTION OF VEHICLE ON ORDERS OF: ❑OFFICER DRIVER ❑OTHER CLIST MO. DAY YEAR El ec-,f [;'w o7 LIP OTHER /HOME PHONE �^ BUSINESS PHONE PRIOR MECHANICAL DEFECTS: NONE APPARENT REFER TO NARRATIVE ❑ El ` A�� - ' ( ( �f\� �/� CMP USE ONLY DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA VEHICLE TYPE INSURANCE CARRIER POLICY NUMBER LINK F]NONE ❑MINOR / ,Nr - o� MOO. �MAJOR E]TOTAL DIROF ION STREET OR HIGHVAY SPEED PCF 1 ICC ❑ TRAVEL O Llat!T PUC ❑ I I G a H CHP GART`{ DRIVEF-S UCEt;SE":U:,79 ER STATE. CLASS SAFETY VEH.YR. MAKE/MODEL I COLOR UCENSE NUMBER STATE ECL.. 3 DRIVER NAME(RBST,MIDDLE,LAST) ❑ i PEDES- STREET ADDRESS OWNER'S NAME ❑SAME AS DRIVER TRIAN ❑ PARKED CITY/STATE/ZIP -OWNER'S ADDRESS rl SAME AS DRIVER VEHICLE LJ BICY- SEX I HAIR EYES HEIGHT WEIGHT BIRTHDATE RACE DISPOSITION OF VEHICLE ON ORDERS OF: ❑OFFICER D DRIVER OTHER CLIST MO. DAY YEAR OTHER HOME PHONE BUSINESS PHONE PRIOR MECHANICAL DEFECTS: NONE APPARENT ❑ REFER TO NARRATIVE ❑ ( } ( ) CHP USE ONLY DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER VEHICLE TYPE ❑LINK F)NONE ED MINOR ❑MOD. ❑MAJOR O TOTAL 01 .0 F JONSTREETORMIGHWAY SPEED PCF ICC ❑ �' AVEL LIMIT PUC ❑ CMP ❑ PREPARER'S NAME ^� DISPATCH NOT)r=)ED REVIEWER'S NAME J•-� DATE ZWED G'L / ��. Q YES ❑ NO [3 N/A CHP 555-Page 1l(Rev. 7-87) OP(042i 87 45344 STPTE OF CALIPbRNIA TRAFFIC. COLLISION CODING. ,,�E DATE OFC LI$KNI TME(�Do l TIC NU'�R OFFICER 1.DNUMBER O MO. ' DAY YEAR J OWN SHAME/ADDRESS PROPERTY NOTIFIED DAMAGE NO DESCRIPTION OF DAMAGE DYES [I SEATING POSITION OCCUPANTS SAFETY EQUIPMENT M/C BICYCLE-HFLMET EJECTED FROM VEH. a 1-DRIVER A-NONE IN VEHICLE L-AIR BAG DEPLOYED 0-NOT EJECTED 2 TO 6-PASSENGERS B-UNKNOWN M-AIR BAG NOT DEPLOYED DRIVER 1-FULLY EJECTED 7-STA.WGN.REAR C-LAP BELT USED N-OTHER - V-NO 2-PARTIALLY EJECTED 8-RR OCC.TRK_OR VAN D-LAP BELT NOT USED P-NOT REQUIRED W-YES 3-UNKNOWN 9-POSITION UNKNOWN E-SHOULDER HARNESS USED 1 23 0-OTHER F-SHOULDER HARNESS NOT USED CHILD RESTRA+NT PASSENGER 4 5 6 G-LAP 1 SHOULDER HARNESS USED Q-IN VEHICLE USED X-NO H-LAP/SHOULDER HARNESS NOT USED R-IN VEHICLE NOT USED Y-YES 7 J-PASSIVE RESTRAINT USED S-IN VEHICLE USE UNKNOWN K-PASSIVE RESTRAINT NOT USED T-IN VEHICLE IMPROPER USE U-NONE IN VEHICLE ITEMS MARKED BELOW WHICH ARE FOLLOWED BY AN ASTERISK(•)SHOULD BE EXPLAINED IN THE NARRATIVE- PRIMARY ARRATIVEPRIMARY COLLISION FACTOR TRAFFIC CONTROL DEVICES UST NUMBER(x)OF PARTY AT FAULT 1 'l 3 TYPE OF VEHICLE 2 3 MOVEMENT PRECEDING I1 AVC SECTION VIOLATED: CITE DES 'Ac ONTROLS FUNCTIONING 1APASSENGER CAR/STA WGN. COLLISION ( /,v 'f-yc"v 9-/ NO B CONTROLS NOT FUNCTIONING' B PASSENGER CAR W/TRAILER A STOPPED 9 B OTHER IMPROPER DRIVING• C CONTROLS OBSCURED C MOTORCYCLE/SCOOTER B PROCEEDING STRAIGHT D NO CONTROLS PRESENT/FACTOR' IDPICKUP OR PANEL TRUCK C RAN OFF ROAD C OTHER THAN DRIVER' TYPE OF COLLISION IEPICKUP/PANEL TRK W/TLR D MAKING RIGHT TURN D UNKNOWN• IAHEAD-ON �r IFTRUCK OR TRUCK TRACTOR E MAKiNG LEFT TURN t E FELL ASLEEP' B SIDESWIPE G TRK/TRK TRACTOR W/TLR. F MAKING U TURN C REAR END H SCHOOL BUS G BACKING WEATHER(MARK 1 TO 2 ITEMS) D BROADSIDE I OTHER 13US H SLOWING/STOPPING A CLEAR E HIT OBJECT J EMERGENCY VEHICLE I PASSING OTHER VEHICLE B CLOUDY F OVERTURNED K HWY.CONST.EQUIPMENT J CHANGING LANES C RAINING G VEHICLE/PEDESTRIAN L BICYCLE K PARKING MANELNER D SNOWING H OTHER•: MOTHER VEHICLE L ENTERING TRAFFIC E FOG/VISIBILITY FT. MOTOR VEHICLE INVOLVED WITH N PEDESTRIAN M OTHER UNSAFE TURNING F OTHER: ANON—COLLISION O MOPED N XING INTO OPPOSING LANE G WIND B PEDESTRIAN O PARKED LIGHTING C OTHER MOTOR VEHICLE P MERGING A DAV!IGHT _ ,D MOTOR VEH.ON OTHER ROADWAY OTHER ASSOCIATED FACTOR Q TRAVELING WRONG WAY B DUSK-DAWN — -E PARKED MOTOR VEHICLE 1 2 (MARK T TO 2!TEMS? OTHER:- � R C DARK•STREET LIGHTS F TRAIN AVC SECTION VIOLATION: CITED D DARK•NO STREET LIGHTS G BICYCLE OYES ONO E DARK- STREET LIGHTS NOT H ANIMAL: B VC SECTION VIOLATION: CITED FUNCTIONING* ❑YES ROADWAY SURFACE FIXED OBJECT: C VC SECTION VIOLATION: CITEDO SOBRIETY-DRUG 1 2 3 PHYSICAL FI!DESUPPERY OYES (MARK 1 TO 2 ITEMS) OTHER OBJECT: ONO Y-ICY D IAHAD NOT BEEN DRINKING (MUDDY,OILY,ETC.) E VISION OBSCUREMENT: B HRD•UNDER INFLUENCE F INATTENTION• C HBD-NOT UNDER INFLU' ROADWAY CONDITIONS G STOP&GO TRAFFIC D HBD-IMPAIRMENT LINK' (MARK 1 TO 2ITEMS) PEDESTRIANS ACTION E UNDER DRUG INFLU.' 71ANO PEDESTRIAN INVOLVED H ENTERING/LEAVING RAMP F IMPAIRMENT-PHYSICAL* JAHOLES,DEEP RUTS' I PREVIOUS COLUStOk CROSSING IN CROSSWALK G IMPAIRMENT Y07 KNOWN B LOOSE MATERIAL ON RDWY.• B AT INTERSECTION J UNFAMILIAR WITH ROAD K DEFECTIVE VEH.EQUIP.: CITED 1 H NOT APPLICABLE C OBSTRUCTION ON ROADWAY' C CROSSING IN CROSSWALK-NOT OYES i SLEEPY/FATIGUED D CONSTRUCTION-REPAIR ZONE AT INTERSECTION ❑NO SPECIAL INFORMATION I E REDUCED ROADWAY WIDTH D CROSSING-NOT IN CROSSWALK L UNINVOLVED VEHICLE A HAZARDOUS MATERIAL F FLOODED' E_IN ROAD-INCLUDES SHOULDER M OTHER% G OTHER•: F NOT IN ROAD N NONE APPARENT H NO UNUSUAL CONDITIONS I IGAPPROACH/LEAVING SCHOOL BUS Q RUNAWAY VEHC:LE SKETCH MISCELLANEOUS i N O INDI ATL Q NORTH 1 Y N �1 Q1 CA \ a V v� i ti OF CAUFbRNIA / iYARRATIVE/SUPPLEI47ENTAL ``'' PAGE ' DATEOFCOWSION TIME(2400) NCICNUMBER OFFICERLD. NUMBER W ONE ')-ONE - TYPE SUPPLEMENTALrx*AppLICABLE) NARRATIVE COLLISION REPORT a SA UPDATE ❑ FATAL O FJTBRUN UPDATE ❑ SUPPLEMENTAL 1El OTHER: HAZARDOUS MATERIALS ❑ SCHOOLBUS ❑ OTHER CITY ICOUJNTTY/JUDICAL DISTRICT REPORTING DISTRICT/BEAT GTATION NUMBER l `>< C & rd LOCATION/SUBJECT , STATEHIGHIYAY REQ TED YES NO 2. er /'✓ a O G a t 3. 64-1,d v - a 4. 5. a a 8. L, o //-- / l' /'v —40&A o 9. - 2 10. 12. T �7Gi sr a,t w a Aho o oloof 13. 14. - _---- 15. Co L 'Amp oz jo, " 16. 17. 18. 19. 20. 21. _.. 22 - -... 23. 24. 25. 26. I 27. 28. 29. 30. 31. 32. PREPA ME- I.D.NUR /MONTH/DA EAR REVIEIIER'SN E MO yJ�A /YE CHP 556(Rev.7-87) OPI 042 Urpr. Wid -kld4pi•I.0 5 87 45312 CLAIM /4� 1- BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, o.- District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT February 23 , 1939 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $60 . 00 Section 913 and 915.4. Please note al;la*"War'ni`ngs 4 CLAIMANT: CATHERINE SECHELLI THELEN f,1;1 0 U b 160 Newbury ATTORNEY: Hercules , CA 94547 Martinez, CA 945,53 Date received ADDRESS: BY DELIVERY TO CLERK ON-, January 27 , 1939 BY MAIL POSTMARKED: January 26 , 1939 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: January 31, 1939 RYIL BATTCYELOR, Clerk epuL, Hall II. FROM: County Counsel TO: Clerk of the Board of Supervisors (V ) This claim complies substantially with Sections 910 and 910.2. . ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: P , _ BY: Deputy County Counsel _. III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (x) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. FEB 2 8 1989 Dated: PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: MAR 2 1989 BY: PHIL BATCHELOR by - Depu Clerk CC: County Counsel County Administrator Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later .than six months after the accrual of the cause of action: Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County. Administration Building, 651 Pine Street, Martinez, CA 94553• C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By ) Reserved f r ler 's ili st p Comex(\Z �eshe.11� "Che�lerl I Against the County of Contra Costa ) I or ) �'A N 2 71989 District) LB C LOR Fill in name ) i c' T qF n f, R11 By The undersigned claimant hereby makes claim against the County of Contra Costa or . the above-named District in the sum of $ (o Q , and in support of this claim represents as follows: ------------------------------------------------------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) --------- --------=-'- =------------- "` ------------ a^-^-' - 2. Where did the damage or injury occur? (Include city and county) -tin �xou da2o' *Ko. res"odir betwen,n o�ind�a o nd �1 �nra.rsta, Cor�tra C©sbo, Cs"it -------- ----------- 3. How did the damage or injury occur? (Give full details; use extra paper if required) a�_ 'fh.n: Ce y c,Ab --- . `n&cpenac Mo �a. inose a-� � S '� jloQ uey CQado.ou apcG�c�n1 e� ,,.p cG z . CLpassr � Can 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? 522, 4+ 3 . C&A 10L u -4 A 26fc e'►• d.c.� � d.L.c.6t) /L44CA6 (over) i 2 -14 4 ?' == GLASS 415 8 9 �. TECHNOLOGY Authorized Glass Technician INVOICE CUSTOMER N E DATE ADDRESSN PHONE _ E CASH CHARGE YEA I MAKE MODEL LICENSE NO. NATURE OF SERVICE CITY. DESCRIPTION PRICE AMOUNT POLICY NO. INSURANCE CO. ADDRESS TOTAL Signature below constitutes acceptance of above service LOCATION OF BREAK performed as being satisfactory and authorization for payment directly to the above Glass Technololgy Dealer. X GUARANTEE: The repair is guaranteed for as long as you own your vehicle. If the repaired area cracks further,does not maintain optical clarity,or fails to pass inspection we will refund your money. Thank you Ilk CLAIM 30ARD 07 SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against. the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT February 28 , 1939 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $1, 152 . 59 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: DIANNE K. "OLIVER County Counsel 1733 Somerset Place ATTORNEY: Antioch, CA 94509 � ��>� 2 7 1989 Date received ADDRESS: BY DELIVERY TO CLERK ON January 251ylahaP9, CA 94553 BY MAIL POSTMARKED: January 24, 1989 I. FROM: Clerk of the Board of Supervisors TO: County Counsel_ Attached is a copy of the above-noted claim. Januar 27 1939 PPHHIL BATCHELOR, Clerk DATED: 5' BY: Deputy L, Hall II. FROM- County Counsel TO: Clerk of the Board of Supervisors (�) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: G BY: , Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (�) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. FEB 2 8 1989 Dated: PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: MAR iJ89 BY: PHIL BATCHELOR by u y Clerk CC: County Counsel County Administrator I Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553• C. If claim is against, a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code ec. 72 at he end of this form. RE: Claim By ) Reserve _ in tamp ED J A N 2 51989 Against the County of Contra Costa ) !�I fi HEL CR or ) Or F ' P I RS CON /.. .. ... ty District) eu Fill in name ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named Districtin the sum of $ J�a., ; �j and in support of this claim represents as follows: ------------------------------------------------------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) ------_._.�u ----Via,--- '----------�- �-�` ------------- I----------- 2. ere did the damage o injury occur? (Include pity and county) Where P19t6 Roal _ bf!-&otjb s.' --- c.1_Lvl , LG1----- C, �._ _�1� _�.�>.ccs11 L-------- 3. How did thetmage or injury occur? (Give full details; use extra paper if required) --------------------------=--------------------- - f-7 4. What articular act or omission on the t of counor distri officrs �eQP Pte' servants or employees caused the injury or damage? `ire were _r0n ftY.A nG s J W'5 iD(v-d W10-5 h1 re Q �' � U��� C.i+�uti �� � �` e � (.� �e (���� �A) med -S hd -1/ w,145ble,td a d ah,pped it i "too mo-/)( AQ- kDo,-d -ho �5&YeZ�l df-t, AJ t L ^ ' ^ . . ' ` ^ Damage Report 2235 09/28/88 Page 1 wpwwwww owiirc3 WjC3K>"r to No ON AE P4 11 ~=======================~=~======~=~~===~=~~~=~= 1950 ARNOLD IND . PL . . CONCORD, CA . 94520 (415) 680-0707 FEATURING STATE OF THE ART EQUIPTMENT 0 TECHNOLOGY IN COLLISION REPAIR Vehicle Owner : Vehiole : Insurance : ....................................—............ ............................ --------- . DIANNE OLIVER 83 TOYOTA 1733 SOMERSET PL CELICA GT HTCH ANTIOCH BROWN/BLAK CA 9450q 1HFY20*1 Work ' (415) 672-2774. Mileage ' . Home : (415) 757-4611 Vehicle ID Number Date of Loss ' 0/00 JT2RA65L2D4019540 ------------------------------------------------------------------------------- -- DAMAGE REPORT Written By JOHN ENDRES -- -------Labor--------- Item Price Metl Mech Oth Paint ------------------------------------------------------------------------------- C 1 Remove 8 Replace FRONT 8RlUI 52-40 .0.4 C 2. Repair 9 Straighten FRONT HOOD CHIPS 1.0 3.0 C 2. Repair X Straighten LEFT FENDER CHIPS 0.5 oo C 4. Repair X Straighten RIGHT FENDER CHIPS O 5 2.0 C 5. Refinish RIGHT r[HO[x EXT 0.4 C 6. Refinish LEFT FENDER EXT 0.4 C 7. Refinish 2-STAGE 2.4 C S. Additional Faint Labor COLOR MATCH ' 0.5 ============================= DAMAGE REPORT SUMMARY =========================== METAL LABOR $ 103 . 20 . . . . 2 . 4 hours @ $ *3 . 00 per hour PAINT LABOR $ 460 . 10 . . . . 10 . 7 hours @ $ 43 . 00 per hour PARTS $ 52 . 40 PAINT MATERIALS $ 192 60 . 10 . 7 hours If * 18 . 00 per hour SALES TAX $ 15 - 93 DAMAGE REPORT TOTAL $ 824 23 ===========~===~========~===~~==~~~=~===~~===~==~=~~~~~~~~=~==~==~~~~~~=~~~=~== Insurance Payable Repair Total $ o Vo Customer Payable' including Deductible * 824 . 03 Adw 'tam a eat, mate 0m#, Vae, aNVA CUSTOM AUTO PAINTING TELEPHONE 689-6117 2520 MONUMENT BOULEVARD - CONCORD, CALIFORNIA 94520 Date _—19=1' / NAME (.%�j t�� ��: ,n� / �r G� ADDRESS CITY PHONE 6 �Z Make i I +/�S c'r f�' Year zs ? Serial No. Prod.Date Mileage License No 11) 6ody Style Insurance Co. REPAIR REPLACE ESTIMATE OF REPAIR LABOR HRS. PARTS SUBLET 4. I j t, ✓ 7/ OD r I i I j TOTAL REMARKS HRS.OF LABOR @$_ L/ PER HR.S C,r✓'_ }-' PARTS PAINT MATERIALS$_�.,�_ $ INSURA CE DEDUCTIBLE SUBLET SALES TAX BY: THIS ESTIMATE IS BASED ON OUR INSPE D DOES NOT COVER ADDITIONAL PARTS ESTIMATE TOTAL OR LABOR WHICH MAY BE REQUIRED fl THE WORK HAS BEEN STARTED.AFTER THE ADVANCE CHARGES$__ WORK HAS STARTED,WORN OR DAMAGED PARTS WHICH ARE NOT EVIDENT ON FIRST IN- SPECTION MAY BE DISCOVERED. NATURALLY, THIS ESTIMATE CANNOT COVER SUCH CONTINGENCIES.PARTS PRICES SUBJECTTOCHANGEWITHOUT NOTICE.THIS ESTIMATE IS GRAND TOTAL$ tA FOR IMMEDIATE ACCEPTANCE. THIS WORK AUTHORIZED BY NO CREDIT CARDS ACCEPTED. / WHEN PAYING BY ®bel glass0 inc. {,t�Q CHETHISPLEASE NVOICErNO�,E REMIT TO: (415) 834-7841 P.O. BOX 657 OAKLAND, CALIFORNIA 94604 DATE: = c - Y REG. NO.— —. SOLD TO: -�1 / ' != ��L l l/i� !< . SHIP TO: n (� 1� C�L-I 1-7 3 SQA PHONE _ rAR MAKEMODEL LICENSE NO. ORDER NO. SALESMAN — a;ti CeLI6 � "t<?S(y-837-F14 o5 ~OTY.. PART OR,SIZE NO. DESCRIPTION ,' LIST .:, NET TOTAL i I c r�4s3 V.1 I N DN l�L 464.(0S 4 z ----------- TOTAL PARTS SALES TAX TOTAL LABOR —CD CONTRACTORS LICENSE NO. Sub- � LOCATIONS: 374136 400 FRANKI.,IN STREET, OAKLAND, CA 94607 ��taSl-4 1992 REPUBLIC AVE., SAN LEANDRO, CA 94577 - %! 2510 MONUMENT BLVD., CONCORD, CA 94520I 1711 BARRETT AVE., RICHMOND, CA 94806 TOTAL AMOUNT DUE j �6 NOTICE ------ ''Under —'Under the Mechanics Lien Law(California Code of Civil Procedure, Section 1181 et seq.)any contractor, subcontractor, laborer,supplier thank you or other person who helps to improve your property but is not paid for his work or supplies has a right to enforce a claim againA your )roperty.This means that alter a court hearing,your property could be sold by a court officer and the proceeds of the sale used to satisfy the �ndebledness.This can happen even it you have paid your own contractor in full,it the subcontractor,laborer or supplier remains unpaid:' CONDITIONS OF CREDIT.,TERMS—A FINANCE CHARGE IS COMPUTED ON APERIODIC RATE OF 11/2%PER MONTH WHICH IS AN ANNUAL PERCENTAGE RATE OF 18.6 ON ANY PREVIOUS BALANCE NOT PAID WITHIN 30 DAYS. 1� YuuuuYk`bux�uXu t� MA • ,n VM C w (,A� cJ Or 00 to N xuV c/. Q7 IQU { � V A t1 CtIAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT F eb ruar v 2 8 l 9 8 9 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $110 . 08 Section 913 and 915.4. Please note all "Warn t, su"11tY ®Ur1Sel CLAIMANT: NEAL .G G. MCDONALD 2620 Lincoln Avenue RE 01 1989 ATTORNEY: Richmond, CA 94804 Martinez CA 94553 Date received ADDRESS: BY DELIVERY TO CLERK ON January 31, .1989 hand del . BY MAIL POSTMARKED: no envelope i I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. Januar 31 , 1989 PpHHIL BATCHELOR, Clerk DATED: y BY: Deputy L. Hall II. FROM: County Counsel TO: Clerk of the Board of Supervisors (v ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( } Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: '- l —�� BY: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present �) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. ? FEB 2 8 1989 Dated: PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant asshown ab shown above. Dated: 2 '"`"" BY: PHIL BATCHELOR by y Clerk CC: County Counsel County Administrator Ilk Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes .of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building,' 651 Pine Street, Martinez, CA 94553• C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By ) Resery /V=A-L Me DON/41-'b ) RE 9 Against the County of Contra Costa JAN 8-9 00 or ) BA EL R District) CL`° NTRp A Cid Fill in name, ) ej �• utv The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $.—/10,0(9— and in support of this claim represents as follows: . ' ------------------------------------------------------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) Ma✓ Zy°, /9Fg /U:is PM ----------------------------------------------------------------------------------- 2. Where did the damage or injury occur? (Include city and county) (/Toc..A•eo ONS. -rawrI4 Or MIL_ /VW or' BRI.fTL_eatV_ U2. • /'/&Meat Z 0wd) &4&Z /vGv douvo\ � rnoutY Or- s7Mv PASLo DAA go, A,%Fr eanrreA caJTA cry. ------------------------------------------------------------------------------------ 3. How did the damage or injury occur? (Give full details; use extra paper if required) 6v14/1,L ,7-'Av.=Lhv6 S.P. /PAM RD. /Et/ W5 rr&JUVj> Ala. Z JAAt: /N AInli lv504—,,q�� ,42(GN7 T-/09E CAR— T/&=S f41 r 7"0_=SP NPL s . =.M/M. ,,v OA Lt S144W?0 /Qt,2=?pAQAe ;S PAMAC7 TuF2aruY ------------------------------------------------------------------------------------ 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? r-Atz-O 2_ -Td M,4(AmA t Ar ' ROAZ) /N .s.4, C0'0001-r/ci,u. Mk T/•W A NumB_=,40_-Gf O>HR 6-�e v�,2(' R0/AIEZ -Y/2-J' /.4j W4A-r REMIT TO: " . & 0•S VlkL4 GK & 6t U1-0 1Lrt JftK GENERAL . OF PINOLE TIRE 730B SAN PABLOAVENUE CREDIT• 50 Oo T.r. PINOLE,CA 94564 APPROVAL -.... 415-724-7200 DPTE : 0123 SOLD TO r✓ / /`' /)/ Q CA$H REGULAR ADDRESS. REVOLVING TIMEPAYMENT f:!:`,fafJ;i v.' iV;" AUTO.CHARGE COMMERCIAL ii CITY STATE, ZIP TYPE f13i'T3, !/fl � 'l'�0 * tVn t_' >c.I')i/1Al'!. 413 t _REE IT ^` `A ui'' F::�i I = ii / n �,/ 'Q ) D , l N TRAI ACCT. _.'t .. ?1 Tt;t.'_ �� .. t %�✓O4 rTi 31-11 T T• /r_•:7 "rpt• !i.)f ;CAR �V+I?eQ '! ;�J ti711^J ' .'• = �r i'"J r..�: r CUSTOMER PHONE NO° '+hilt ''i"SALESMAN - '.PWWONO. MAKE u YR. NO. +LICENSE NO. MILEAGE HOME BUSINESSyO/{I(J/T14 / 4/ � O yv yy1 TIME PROMISED G UNIT EXCISE UNIT PRICE. EXTENDED- PRODUCTCODE SIZE'' PLY I DESCRIPITION � � r l r�: F i T �� t.INCLUDING• QTY TOTAL - INDICATE 2 DIGIT T EXCISE•TAX alk= PIC BELOW ) lSS o wew b Ll D�� �� 5 S / .5 109-It if e oifibnoo brls ern•ipYgdt 011 ;nril uC, ,ni )3u:_�fni ;L.^7z s f-1 !.fJ_:JJ&Y1'f , 11 f.J_F J33 of :3YLJ8 ;:ri. L rr,:z. .....+v u�livu.!��l:�lu .:_„ 'J :,c� }�l..rr.�.�:.lc •.n„ ,J!scn.I:;s;:r.,.. �,,:.: r�Jr,.71ta�;. .0 cit,:: tvr.:n_J a a.l � n,;;•r:.: aro ,It eldsyr. ; bns :ib azonbq#de-w 10"0 ) or cif1- .r _ ;. �1 i'u.`�.Ei' ifilltl/r� :� ---- ��� ed! •,;J 1 f -Avel t;` b%�Iliri114ir ''egir"! , ?i'iIDel 10; r, ink,16d 1 _ e,oE, (9ni Ji,s 9j!#6r,00[:91 3'Y T ?A9 f_'3;iJC"-7` '' f i11ni 11f-. . . $ i, 0 1`" t-: :LfI•�/L=1 lSC7X, � I 1 ` _ :. �it'J1 /.<il:. _ U ..:1 :i.-`G::.+•,!•.,'..i 1' t, 'YJ. _• ..=1; .,,-:JU =.:1 �7r.i J1.. ,_ .1/'1 tt_.r:ls :t„ ... nL 1-- _� 9>;1Sf10 9or=snit C3idt�.) i?nLf19i Isif:SC k3 {lf:•#ti0 kP. ,I C }nCiCJ nsIl+.±`, b: n; 110 sq 1�CM Ul i r SIZE PLY DESCRIPTION OF TRADE IN QTY AMOUNT # y i - RASE _ A.TOTAL RCHANDISE k -AND O RVICE J:U! Vv:a"41' :11�J1. :l,{J [iJ ,uC..Ji _... ...a.�c �`•• _ +��•• =t ss ..+ r._ J ,r �e .I„_ .., •.� �' �t!J 13`�PL`US c AMOUNT TAXABLE Of 19V3rioif�:ti o\G8' 10 Ci�G -1.0 nv`� Jf. -'I" b tai. '1.,.1' 1 ' Jr, •:SALE$; I ) ° � , 1., � n �:.1�,3 „kat9�i (ii # '•i'-TAX= 1 I C.LESS EMP.INITIAL D-a 0 G'?A 2MIA+O JJA CST TO3L,'EgUa G1. ?± fr?7 T.f'3?�;) 931 iii'iif 30 DOWN a" 1 r PAYMENT YOA _AL!" Wit:-iifATEt0 233lVR:32 >30 2100;0 10 Ra.lT?26°ili,�)A t� � r�'�rp3t D'3&s� ia�#t 11 r 1 I- LESS TRADE IN . TO(,: JJls. a ROTO(] �1IT Y8 fi3QUiU3F;311 r"2/C��: i+3, rAtLOWANCE�� ' r ti iU3��)-I Fvc .�,� LZir 1,'`:T fLr E+1af1 TRADE-IN TOTAL(SHOW IN 'D") < 1 = I LESS OTHER t ® 1 I DEDUCTIONS TAG NUMBERS y ,.ri•• ! , a n REC'D;BY ,• , �� F.•NET AMOUNT 1Lic t: .11lsl_r ,r:Oifgil;_+O ,F ,FIs_ ,� trli# .:rlJ fs riai> , .Jr.l.�t,,,t hiEt1 Jon i,e fk- ?� q I;ri#11 DUE J;iGtJ! 2n61i i If:O 9f1f;f0-?iBb O i _. _• _ s 1 J.PLUS_. DEFERRED INSTALLMENT TERMS ' FINANCE CHARGE ANNUALcfsr : .PAYMENT PRICE I,5.1� t:'.imll rico, ., 1 f` k, - -i-110?7J f 0i'l({ cMz;,.J J�,crtj L)tit,1vv.l! ;,tort tia„t rv> e M&NTHLY PAYMENTS OF $ I K ” PERCENTAGE $'-'T- TiOS-s 11I�f 11 Ct bt, ,t� ra;i;;�+r r� ,r.. :.7� F;s� 0,',Ju,� ,.t_+c:.�_ Fe01 1011 'OZO I O a ii � ?n lrlsr,� COMMENCING 10 19 ARE DU ` - 1 - TOTAL OF PAYMENTS RATE_% + t MONTH —DAY' VEA i� 1C� cU r{:IiSyti`I. (ITEMS A+B+J- ON THE 10th OF EACH MONTH.UNTIL PAID IN FULL. i -,p,ctt TERMS AND;CONDITIONS ON REVERSE SIDE-ARE:PART OF-•THIS AGREEM ENTibbs nl SECURITY AGREEMENT aADJUSTMENT'POLICY AGREEMENTAND ACKNCWL'EDGEMENTOF.RECEIPT Cti§26mer hereby represents that he has suffered no damage and that there are no unresolved claims against General Tire arising fFom or'iAiting to the tire of tubeior-wfiich ihls.adjustment Invoice is being issued and hereby releases and waives all claims or causes of action known or unknown which Customer has(or may in the future have)arising from or relating to said tire or tube. Customer grants to Secured Party-Seller a security interest in the property described above.If Customer defaults in payment of any obligation,Secured Party-Seller may declare lheentire indebtedness .due and payable and may exercise all rights and remedies allowed by law Including the right to take back the merchandise and I or hold Customer liable for damages including,a)the unpaid balance,b)at- tor-ney or c charges,and c)expenses of retaking and selling the merchandise. =.Cris reby acknowledges receipt of the property described above and agrees that Secured Party-Seller's Limited Adjustment Policy shall provide the SOLE AND EXCLUSIVE REMEDY for all clai gainstErcured Party-Seller arising from or relating to products covered by said adjustment policy. Se arty-Seller Cu er t By _ By 81004WM _ - .- - . CUSTOMER ORIGINAL -- --- - -- _ --- -- . _-__—•-- I . GENERAL REMIT TO: J & O'S MUCK 41, &U 110 kAkyJ Etre TIRE OF PINGLE 7306 SAN PABLO AVENUE ;. .'' :' cREolr 50 Do •T' PINOLE,CA 94564 APPROVAL 415-724-7200 DATE 0226 22V SO D TO CASH REGULAR :..... �:-�. C, o A. i ADDRESS REVOLVING TIME PAYMENT Lf, r1�•O T Us 7'vil i,1`. G11_ AUTO.CHARGE COMMERCIAL CITY 1 STATE ZIP TYPE iltif��� '' 41;3A_ i HTRO� 732' _JI��Fi32 UV14�j'^//Irj:i;j:?'f'�� :1 3fiT 30 7cil 3F EDIT 1�J}z 44 YE 3f1314 NAT'LACCT., :2 2. f13T Uv': �IIiIUVl0' f U '°s''i 1U2 a 3CIOVtnI :1111 ,A :;,! r, h I 30 '307 l HTIiN 'n _ ;.�. _ - �.' �;: 1`v- k'.�`.'1�,.�"'= �,i';` -t)i-".�`-�="'CUSTOMER"PHONENO�1'C''I'-!A ` I/tt•SALESMAN�• PO/WONO3 - MAKE YR.N NO.` YLICENSEN0. MILEAGE HOME BUSINESS 3 J C ► TIME PROMISED ` 'r UN UNIT PRICE PRODUCT CODE IT EXCISE EXTENDED SIZE. PLY .DESCRI,PTION ; TAX' r INCLUDING q-qTY INDICATE 2 DIGIT lirItial 1 if SJi< 1 J ��`� i;,^, .f , .1 r:iO J ,.Excise raxt,l i .:•:.: TOTAL PIC BELOW o'.i'irl a n ( o 1; li;7el f^Pt19#ni " i u.oap.s f-I3:l_f32-YTS c1rJ�c L!)1; Ot 'i ., 13Y £l o h )� !m'•1 1 f of J.J _ .�, � 11 iiia j1, :7_L.. Iii iiUfigl)Jit) ciiajI i lFi,°�;1 is_lil U•..rJ C.tlt•j ,111:;,1 Ilit,)[,Iit tii; iV)iloill`D' it!Z:iU�l�IJ I'1:3 1 C.IO 111t7Y 3tflij 111 91dsyr , brls •IUb P_0nb13tdebn e if O his. i j Ir 1 1 l g3ytjFj t ri1 hl(': ' erl rr'ls, 92ibnsdo-9m elit Ae o?A#v;m neilgolp#i ts`F'3j j3 3 yd,b9f#irrn9g oglsrie n•sitosllo0 i0 r9nlrf � yns n11;l;lan! ��nslsd. r yoof G gilf: 2 cni;tslo;; 10 Gs: nogX3 ii ;}:: CJi U11upul s 11Jblzju U tvf U"e1UGGUlj1171 II XJ iJ(.iJ 4 u1 1).IIIV',Hyl tbill r'l= IIfO ;C IL;I)I,)IIL)J IIibl IG_ :l UIIV a I -9?, kz: iai, n0 t:�26C a-,Edo 9;n;nit' rift; In1119't Isi#?5q G nir71d0 #•t G :'Ub.#nUL ll� flut er1f ),)nsvb� ni I �s ysrn 1311-1h .fin 11 n,h l{];A4`: 1 A TOTAL MERCHANDISE SIZE- PLY DESCRIPTION OF•TRADE 1N QTY AMOUNT 1 AND OR SERVICE r 10- ,Ljr .. 10 0: ".Z.-LU libel ;ti)'C.7,y.i:;ue.oi r'I__JJ_;J 1`I Iil t 11.t-i1lt+J.:.ic1 : lAle 6t'.11 14 C'.✓:J: :Jill ui Nrjg!0L S', AMOUNT TAXABLE .te2S1 2i 19V9doil1 ) o�°-10 00.8?, io l�glsri s# I'b sb 0 ns7# nom fiuslflh n Jr, ,jS�wS tdb8�9 C.LESS EMP.IN 1`13' OVA 2MIA10 .1JA O'f T03G8U2 �i i�,46ir100 T((136J ft3Mtf26100 8f 'T':30 rFAYIvIENir1 YI�A` �, ;1`J Its l� W -HU Ci3 IIAT80 2.301VR33 60-2000a 30. 63.1.132 3 IT Tci71;^c7r'i <. 3221` �_'C �0 i' T�? D LE S RAOE-i.NN� J 70� _fJQ!i2 60TF�3t7 3NT YS ># tC1VIUg63H Y63•J ?0?f1 3036314 ?03 �obn,3 T►'. T14'l !i . C� }AtLOWANCE� ty �0LJ343I1-I POT 330 3HT Y5 CIA'I 2Tiit E4iR ssOorHE�Rx� � } TRADE-IN TOTAL(SHOW IN "D") , DEDUCTIONS'. TAG NUMBERS -iuq b9ililsup ,noitgo wo 1s ,slB2 #O:emit_91`11 1s t12 FEC�D LTI ni bisq Ion ,i 96i1q 93srI31uq i9fi1 11 .i NETrAM,O,UNT nai#as2ns11 i0 #sb orif 16 aysb O£ •'`.:: DUE 'µ t _ ._ .. .. _ •• _ � J PLUS -- - DEFERRED INST�LLMENTTERMS ' FINANCECHARGEF ANNUAL18ni (PAY MENT,PRICE11S9d i 91Q1n1 ns 19i1r n Vv talRa IPM- Bnoo-nor. f cilt,ty l;u�1`.l G!I : ive3i su errs vu wtl MONTH PAYMENTS OF PERCENTAGE' ism ii 709 ilut ni 3 3V6C1 21 Sub nUOms in9rn'if61? eni ,nEiC ci if'G213 0f 16n 920I rib UC( t1 r�( fvtn COMMENCING 10, 19 ARE bIJr TOT L 8`117 PAYMENTS RATE=SIO MONTH onr r—€a� =;1n9rnf tst iQ•1t�19D97 (ITEMS A+B+J-E) ON THE 10th OF EACH MONTH UNTIL PAID IN FULL: 3�1sri TERMS'AND_C,,ONDITiONS,O.N-REV,ERSE•S.IDE_•ARS:PARTOF;THIS,AG.REEM�NT �as`ni SECIJRITYUREEiMENT V'ADJUSTMENT,POL'ICY AGREEMENTrAND'ACKNOWLEDGEMENT-OF RECEIPT, Customer hereby represents that he has suffered no damage and that there are no unresolved claims against General Tire arising trom`or relattng'toithe tf?e nt tbbe'for which this;adjustment Invoice is being issued and hereby releases and waives all claims or causes of action known or unknown which Customer has(or may in the future have)arising from or relating to said tire or tube. - • Customer grants to Secured Party-Seller a security interest in the property described above.If Customer defaults in payment of any obligation,Secured Party-Seller may declare theentire Indebtedness due and payable and may exercise all rights and remedies allowed by law including the right to take back the merchandise and I or hold Customer liable for damages including,a)the unpaid balance,Wet- torney or collection charges,and c)expenses of retaking and selling the merchandise. Customer hereby acknowledges receipt of the property described above and agrees that Secured PaitySeller's•Limited Adjustment Policy shall provide the SOLE AND EXCLUSIVE REMEDY for all claims against Secured Party-Seller arising from or relating to products covered by said adjustment polfoy.. _ I _ ' 1`f� l;.-<��" r�/.�-�( 'i-;.�. ""ct•iC.' .li� ' Secured P ti Cust BY BY 4 810a.06% •" .-.. EXTRA COPY - .• _ _ �•- _. CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT February 28, 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $250, 000 . 00 Section 913 and 915.4. Please note all MWI 5s' �.a�,����' CLAIMANT: DAN GRAINGER c/o Ronald P, Golman �0 0 i 1 ATTORNEY: Bradley & Curley Ma rtinOZa CA 94553 100 Bush Street #2400 Date received ADDRESS: San Francisco , CA. 94104 BY DELIVERY TO CLERK ON January 30 , 1939 hand del . BY MAIL POSTMARKED: no envelope I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. IL gATCHELOR, Clerk DATED: February 28, 1989 �b: Deputy L, Hall II. FROM: County Counsel TO: Clerk of the Board of Supervisors O (°' ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: (� — BY: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. p Dated: r E B 2 8 1989 PHIL BATCHELOR, Clerk, By �4/—��,�eputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. MAR 2 1989 Dated: BY: PHIL BATCHELOR by ty Clerk , CC: County Counsel County Administrator I v J� 6ilai� ttb: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553• C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. y. If the claim is,against more char. one public antity, Separate claims mast be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By ) Res r _ stamp DAN GPAINGERK E . j Against the County of Contra Costa ) JAN 3 0 1989 J ao or ) pH11 A7 ER GRS District) CLE c a Fill in name ) Dep By The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ 250,000. . and in support of this claim represents as follows: ------------------------------------------------------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) October 29, 1988; approximately 9:30 a.m. ------------------------------------------------------------------------------------ 2. Where did the damage or injury occur? (Include city and county) Intersection of Willow Pass Road and Mt. Diablo Street, Concord, Contra Costa County. ------------------------------------------------------------------------------------ 3. How did the damage or injury occur? (Give full details; use,extra paper if required) See attached. ------------------------------------------------------------------------------------ 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? Negligent construction, failure to supervise construction, and failure to properly maintain above-named intersection; negligent design of intersection and use of improper pavement materials. (over) Io r i� F. t 3 . On October 29, 1988 at approximately 9: 30 a.m. , Dan and Catherine Grainger were traveling down Willow Pass Road on their motorcycle. When said parties began to travel through the intersection of Willow Pass Road and Mt. Diablo Street a vehicle nearly struck Mr. and Mrs. Grainger. Due to construction at the intersection, overgrown shrubbery, the intersection design, and slippery pavement tiles, when Mr. Grainger attempted evasive action from the oncoming vehicle, the motorcycle slipped out from under him resulting in injuries to both Mr. and Mrs. Grainger. 7. a) Estimated present and future medical bills $ 20, 000 b) Estimated present and future wage loss 50, 000 C) Present and future pain and suffering 180, 000 TOTAL $250, 000 8. Witnesses: Dianna Reidger, 2156 North Sixth Street, Concord, CA 94519; Lynn Spawn, 3105 Fitzpatrick Drive, Concord, CA 94519. List of doctors and hospitals is attached. 9 . See attached expense list. Y 1 i i Accident 10/29 Expenses Date Expense Charged By Amount Billed Amount Amount Amount Receipt Of To Metro Paid By Paid By Paid By Expense Date Metro - Us Guerrero --------------------------------------------------------------------------------------------------------------------------- 11/22/88 Milk of Magnesia Safeway $3.18 11/29/88 $3.18 Y 11/07/88 CPM Machine Dep. Cresent Health Sery $81.75 $81.75 Y 11/11/88 Support Hose Longs Drugs $8.51 $0.51 Y 11/24/88 Tele 10/29-11/9 Pac Bell $72.97 $72.97 Y 11/21/88 Home Care Frances Nilon (36.00 $36.00 Y 11/22/88 Packing Help Frances Nilon $12.00 $12.00 Y 11/14/88 Home Care Frances Nilon $42.00 $42.00 Y 11/16/88 Home Care Frances Nilon $18.00 $18.00 Y 11/06/88 Movies thru 11/12 Video Outlet $12.00 $12.00 N 11/06/88 Movies thru 11/12 Fry's $9.60 $9.60 N 11/05/88 Dinner to Hospital Barney's Hickory Pit $11.75 $11.75 N 10/29/88 Cathy's Levi's $30.00 N 10/19/88 Cathy's undies $6.50 N 10/29/88 Dan's Shoes $40.00 N 11/06/88 Calcium Tabs Fry's $9.53 $9.53 N 11/03/88 Two Gowns Penney's $20.00 $20.00 N 11/03/08 Slippers Penney's $20.00 $10.00 N 10/29/88 Ambulance Service Regional $243.60 11/10/88 $207.06 $36.54 Y 11/11/88 Pain Pills Fry's $9.10 11/29/88 $9.10 Y 11/17/88 Pain Pills Fry's $9.10 11/29/88 $9.10 Y 11114/88 Anesthesia Dr. Stein $680.00 11/29/88 $570.00 $102.00 Y 11/22/88 Pain Pills Fry's $9.10 11/29/88 $9.10 Y 11/15/88 Dan's Time Off Work To Date 80 hrs Lost Opportunity Grainger Graphics 12/15/88 Help at 66 Cindy Warner $500.00 $500.00 Y 1 L � t I Accident 10/29 Expenses Date Expense Charged By Amount Billed Amount Amount Amount Receipt Of To Metro Paid By Paid By Paid By Expense Date Metro Us Guerrero --------------------------------------------------------------------------------------------------------------------------- Help at 66 Frances Nilon 12/16/88 Repairs to M/C Bob Dron HD $2,032.00 $2,032.00 Y (Est) including jacket 10/29/88 Dan's Pain Pills longs $9.10 $9.10 N 10/29/88 Cat Emergency Room, Mt Diablo 10/29/88 Dan Emergency Room Mt Diablo $146.41 12/09/88 y 10/29/88 Cat's X-ray Diablo V Redilgy $47.00 12/09/88 $39.95 $7.05 y 11/05/88 Cat's X-ray Diablo V Radilgy $27.00 12/09/88 $22.95 $4.05 y 10/29/86 Surgery Dr. Nottingham $1,720.50 01/12/89 Y 11/18/88 Ortho stocking Hittenberger5 $60.00 12/06/BB $60.00 y 12/28/88 Painting Help Steve Nolan $180.00 $180.00 Y 12/31/BB Movers Maters $658.15 $632.00 Y 11/24/88 Pic bike/shoe/pants longs $4.00 11/29/88 $4.00 N 11/27/88 Cathy's Pain Pills Fry's $8.25 11/29/88 $8.25 y 11/30/88 Parking Palace Garage $15.00 $15.00 y 12/01/B8 Cathy's Pain Pills Fry's $22.20 12/09/88 $18.87 $3.33 y 11/06/88 Cathy's Hosp Bill Mt. Diab Hasp $12,159.19 12/09/BB y 12/17/88 CPM Machine Dep. Cresent Health Sery $75.00 $75.00 Y 12/12/88 Cathy's Pain Pills longs $7.70 $7.70 Y 12/12/88 Cathy's Pain Pills longs $15.05 $15.05 Y 12/16/88 Help at 66 Steve Nolan $59.50 $59.50 Y 12/18/88 Excess phone bill Pac Bell $100.00 $100.00 Y Normal bill is between $50 & $60 10/29/BB Mt Diab Hosp $86.00 12/01/BB $73.10 $12.90 Y 12/12/88 Cathy's Pain Pills longs Drugs $15.05 01/12/89 $15.05 Y 12/09/88 Cathy's Pain Pills longs Drugs $7.70 01/12/89 $7.70 Y L � 1 � Accident 10/29 Expenses Date Expense Charged By Amount Billed Amount Amount Amount Receipt Of To Metro Paid By Paid By Paid By Expense Date Metro Us Guerrero --------------------------------------------------------------------------------------------------------------------------- 12/13/88 Cathy's Pain Pills Fry's $13.10 01/12/89 $13.10 y ------------------------------------------------- Total Expenses $19,352.59 $939.93 $2,251.91 $2,032.00 QTY. UNIT PRICE DESCRIPTION AMOUNT AMBULANCE INC. J Mil_A C_ -S iEET T,• FREMONCA 94538 _ Alt MAEl+'s'AA0,U1ANC E :I INC-` ZZZ94964z DIN. Of :.11i�S AONT,CA 94537-7780 "<• _ ., LAMEDA COUNTY ONTRA COSTA COUNTY i _+:ly' _ :)r _�'i.i-! '�.:. _ __.=v1.t^32'_ n� J..J °:�'•J r-r. ��i . .0 FREMONT,CA 94537-7780 s Y ' .4INA:^.:2P3�A�J�'y'r� 3T4YE 1t G I SUPPLIES AND RENTALS J—WHEELCHAIR SERVICE SEE REVERSE SIDE FOR FlNANCE TERMS 8 BILLING ASSISTANCE _ ,,AMOUNT DUE Z 4.�.b 0 TRIP NO. CALL RECEIVED - FROM ":FO ' -t EED OF 0�g2j >.: 7 Fi j = 1A3LT T. 01A;LJ INJURY A _TL/4cco NO. : �21117i 67?7312 ;vim ,;r,k1 Gr. M0 1802 AL ICANTE CT( .41 ..1.• 6 �.C.•I.V'^i!IJ7 V:a 4452 18D2 ABY : C"i`.T :4 �_ 7� r1 .E ? Y � • BACON ST, SI.I.TTF #1? PHONE TAX I.D. • TO REMIT TO !PtiI TEL 5 R 4 T)tl�iFF" �RnRFRT .1,. STF T M M,T;)., Y T me (70!.IRT 2299. '!1A.(nN-:9T.St I r rE #9 r.!l►�h;.rlr r? r4 94"i? �'CMCnI�n s C:A94C20 PLEASE RETURN UPPER PORTION WITH YOUR PAYMENT _ �r PLEASE RETAIN THIS PORTION FOR YOUR TAX RECORDS FROM ACCOUNT DATE ROFIFFel ,1,. STE:T N M, T), , T�i� CP PC. 11 /14/'RE" SV('S AT; MT, n I A L.C1 H.09P I TA!•. 3 N PT PATIENT RIFT-1) FIY P. N10TT T ri{?HPM CATHEP T NIF GRA T�I G F P SERVICE . • CODE DESCRIPTION J%MOUNT T•r,?/ ,9/s•Rft ?. .. ,F,-34 OPFN RED, TN.T, FX 690. 00+ P T GHT T T R T Al. P1,ATFAU ***A JEmTHE9.14 T MF*** 3 HR..S,, 20 M N., SEE REVERSE FOR EXPLANATION OF CODES IVIS" H4t.IF r-ITI..I.FP YO!.IF,' TM910 ,ANCt=, •' t fs�r;?: r:)r:? •�•>f•>f•+F 1• �1 it- t6.88 t tj VA 7r' Y1 r�5 C 1 55 • `' ��N o l oM10� S� . .03SV � � fir•- .�y2� 4 ' . . Y � � w ' r • PACIFIC[]BELL.. A Pacific Telesis Company Account Number 415 672-7312 546 N 7 Page 5 Statement Date Nov 8,1988 I&T • Questions IFor billing questions call: No Charge 1 800 222-0300 Calls Itm Date Time Min * Place and Number Called Charge 1 Oct10 419P 4 DD SACRAMENTO CA 916 448 1501 .84 2 Oct10 752P 1 DE LAS VEGAS NV 702 389 3968 .19 3 Oct17 1143A 1 SD SAN FRAN CA - 397 5533 From 2.06 KINGMAN AZ Calling Card 4 Oct18 211P 2 SD SAN FRAN CA - 397 5533 From 1 .38 GRNDCN AZ Calling Card 5 Oct18 213P 2 SD SAN FRAN CA - 477 6431 From 1 .38 GRNDCN AZ Calling Card Oct26 630P 10 DE VAN NUYS CA 818 784 5712 2.04 Oct29 342P 1 DN WLOSANGELS CA 213 472 7687 .23 8 Oct29 349P 1 DN VAN NUYS CA 818 784 5712 .23 9 Oct29 350P 7 DN STOCKTON CA 209 477 6214 .82 10 Oct29 357P 8 DN CLMNTSNDMS CA 714 596 2878 1 .24 11 Oct29 405P 1 DN SANFRNANDO CA 818 360 7372 .22 12 Oct29 125P 1 SN WLOSANGELS CA 213 472 7687 From .73 CONCORD CA Calling Card 13 Oct30 834P 13 DN WLOSANGELS CA 213 472 7687 1 .96 14 Oct31 937P 9 DE WLOSANGELS CA 213 472 7687 1 .84 15 Nov 1 813P 11 DE VAN NUYS CA 818 784 5712 2.23 16 Nov 1 827P 3 DE LAS VEGAS NV 702 388 2028 .52 17 Nov 1 851P 9 DE STOCKTON CA 209 477 6214 1 .39 18 Nov 2 907P 9 DE VAN NUYS CA 818 784 5712 1 .84 19 Nov 3 754P 7 DE WT•nS NGEr c CA 213 472 7687 20 Nov 4 841P 8 DE STOCKTON CA 209 478 3050 i .24 21 Nov 5 217P 19 DN WLOSANGELS CA 213 472 7687 2.82 22 Nov 7 827A 1 DD WLOSANGELS CA 213 472 7687 .39 23 Nov 7 301P 6 DD WLOSANGELS CA 213 472 7687 1 .59 24 Nov 7 352P 1 DD LAS VEGAS NV 702 389 7338 .30 25 Nov 7 355P 1 DD LAS VEGAS NV 702 389 3968 .30 26 Nov 7 356P 2 DD LAS VEGAS NV 702 388 2028 .55 27 Nov 9 852A 1 DD LAS VEGAS NV 702 389 3968 .30 28 Nov 9 853A 1 DD LAS VEGAS NV 702 389 7338 .30 29 Nov 9 905A 2 DD LAS VEGAS NV 702 388 2028 .55 30 Nov 9 910A 1 DD LAS VEGAS NV 702 368 4114 .30 a See Rate Key on Reverse Call Subtotal $31 .24 Monthly Itm Charge Charges and 31 State Surcharge .91 Credits 32 California Regulatory Fee .02 33 Billing Surcharge .37a 34 Communication Devices Funds for Deaf and Disabled .12 35 Tax: Fed: .96 911 : .12 1 .08 Monthly Charges and Credits Subtotal $1.76 Total AT&T Current Charges $33.00 This portion of your bill is provided as a service to AT&T. There is no connection between Pacific Bell and AT&T. You may choose another company for your long distance calls while still receiving your local telephone service from Pacific Bell. 6 357 SP47 4156727312546 N 7 6020A 94521 CR24 167 9053 3385 PACIFICQBELL., t A Pacific Telesis Company Account Number 415 672-7312 546 N 7 Page 3 Statement Date Nov 8,1988 Pacific Bell • Service Itm Date Time Min * Place and Number Called Charge Area 1 Calls 1 Nov 3 335P 14 SD SAN FRAN CA - 477 6431 From 2.73 Continued CONCORD CA Calling Card 2 Nov 3 356P 6 SD OAKLAND CA - 655 3096 From 1 .27 CONCORD CA Calling Card 3 Nov 4 508P 1 DE SAN FRAN CA - 922 5040 .17 4 Nov 4 1049P 5 SE CONCORD CA - 672 0627 Coll 1 .31 5 Nov 4 1008A 1 SD SAN FRAN CA - 434 2901 From .65 CONCORD CA Calling Card 6 Nov 4 1115A 10 SD SAN FRAN CA - 434 2901 From 2.09 CONCORD CA Calling Card 7 Nov 4 151P 16 SD SAN FRAN CA - 434 2901 From 3.05 CONCORD CA Calling Card 8 Nov 4 820P 2 SE SAN FRAN CA - 397 5533 From .68 CONCORD CA Calling Card 9 Nov 4 822P 3 SE SAN FRAN CA - 397 5533 From .79 CONCORD CA Calling Card 10 Nov 4 832P 20 SE SAN FRAN CA - 397 5533 From 2.70 CONCORD CA Calling Card 11 Nov 5 912P 23 DN SAN FRAN CA - 922 5040 1 .50 12 Nov 5 1220P 7 SN SAN FRAN CA - 397 5533 From. .88 CONCORD CA Calling Card 13 Nov 7 858A 1 DD SAN FRAN CA - 362 8783 .25 14 Nov 7 927A 12 DD OAKLAND CA - 339 2810 1 .65 15 Nov 7 1031A 12 DD SAN FRAN CA - 434 2901 2.01 16 Nov 7 337P 1 DD OAKLAND CA - 339 1174 .22 17 Nov 8 821P 2 DE OAKLAND CA - 547 3829 .24 18 Nov 9 815A 4 DD SAN FRAN CA - 434 3080 .73 19 Nov 9 855A 3 DD SAN FRAN CA - 956 3169 .57 * See Rate Key on Reverse Service Area Call Subtotal $60.74 Zone 2 Itm Date Time Min a Zone Place and Number Called Charge and 3 Calls 20 Oct29 407P 10 DN 2 DANVILLE - 866 1205 .10 21 Oct30 1247P 1 DN 3 BERKELEY - 540 5153 .04 * See Rate Key on Reverse Zone 2 and 3 Call Subtotal $.14 Regulated Itm Charge Other Charges and 22 Credit for Over Billing of Taxes .54m Credits for Monthly Services on Oct. 1988 Bills Regulated Other Charges and Credits Subtotal S.34cR Regulated Itm Charge Monthly Charges Basic Service and 1 Flat Rate Service 8.35 Credits Optional Service(s) 1 Touch-Tone Service 1 .20 6 357 SP47 4156727312546 N 7 6020A 94521 CR24 167 9053 3385 PACIFICOBELL.. A Pacific Telesis Company Account Number 415 672-7312 546 N 7 Page 2 I Statement Date Nov 8,1988 PACIFICEJBELL_ • Service Itm Date Time Min a Place and Number Called Charge Area 1 Calls 1 Octll 616A 1 DN DANVILLE CA 829 1795 .08 2 Octll 426P 4 DD LOWER LAKE CA 707 994 4640 1 .33 3 Octll 441P 1 DD OAKLAND CA - 339 1174 .22 4 Oct11 442P 3 DD SAN FRAN CA - 397 5533 .57 5 Octll 444P 1 DD SAN FRAN CA 434 2901 .25 6 Octll 928P 1 DE RICHMOND CA - 222 3851 .15 7 Octll 1235P 1 SD MARYSVILLE CA 916 673 0676 From .74 SACRAMENTO CA Calling Card 8 Oct14 330P 4 DD SAN FRAN CA - 397 5533 .73 9 Oct14 333P 1 DD SAN FRAM CA - 477 6431 .25 10 Oct14 334P 1 DD SAN FRAN CA - 477 6431 .25 11 Oct14 349P 1 DD SAN FRAN CA - 477 6431 .25 12 Oct14 349P 1 DD SAN FRAN CA - 397 5533 .25 13 Oct14 459P 1 DD RICHMOND CA - 222 3851 .22 14 Oct14 638P 10 DE RICHMOND CA - 222 3851 .97 15 Oct18 1005A 2 DD RICHMOND CA - 236 9111 .35 16 Oct21 914A 1 SD W ANGELES CA 213 472 7687 From .80 BARSTOW CA Calling Card 17 Oct24 757P 9 DE UKIAH CA 707 468 5233 2.01 18 Oct27 630P 6 SE CONCORD CA - 672 0641 Coll 1 .36 19 Oct28 715P 1 DE SAN FRAN CA - 922 5040 .17 0 Oct28 735P 1 DE HAYWARD CA - 537 5228 .17 Oct29 345P 4 DN UKIAH CA 707 468 5233 .53 22 Oct29 502P 3 DN VALLEJO CA 707 557 4293 .16 23 Oct29 613P 3 DN SAN FRAN CA - 673 1281 .22 24 Oct30 1106A 19 DN DANVILLE CA - 829 1795 1 .02 25 Oct30 226P 2 DN PLEASANTON CA - 462 1309 .16 26 Oct30 804P 24 DN SAN FRAN CA - 922 5040 1 .57 27 Oct30 751A 7 SN VALLEJO CA 707 557 4293 From 1 .32 CONCORD CA Calling Card 28 Oct31 704A 2 DN SAN FRAN CA - 434 2901 .16 29 Oct31 928P 9 DE SAN FRAN CA - 922 5040 1 .07 30 Oct31 1055A 1 SD SAN FRAN CA - 362 7489 From .65 CONCORD CA Calling Card 31 Oct31 1057A 2 SD SAN FRAN CA - 421 3120 From .81 CONCORD CA Calling Card 32 Oct31 253P 12 SD SAN FRAN CA - 477 6431 From 2.41 CONCORD CA Calling Card 33 Nov 1 1131A 1 DD RICHMOND CA - 222 3851 .22 34 Nov 1 1155A 1 DD SAN FRAN CA - 397 5533 .25 35 Nov 1 1157A 3 DD OAKLAND CA - 465 1848 .48 36 Nov 1 1208P 4 DD BENICIA CA 707 745 5018 .38 37 Nov 1 1212P -2 -DD-SAN FRAN ---CA ----397- 5533 - - ------ --,41 38 Nov 1 1214F 3 DD SAN FRAN CA - 362 5758 .57 39 Nov 1 1218P 2 DD SAN FRAN CA - 397 5533 .41 40 Nov 1 759A 2 S3 SAN FRAN CA - 434 2901 From .66 CONCORD CA Calling Card [45 Nov 1 817A 8 SD SAN MATEO CA - 342 2610 From 2.25 CONCORD CA Calling Card Nov 1 911A 1 SD OAKLAND CA - 452 4911 From .62 CONCORD CA Calling Card Nov 1 1101A 13 SD SAN FRAN CA - 477 6431 From 2.57 CONCORD CA Calling Card Nov 2 1006A 32 SD SAN FRAN CA - 477 6431 From 5.61 CONCORD CA Calling Card Nov 3 1102A 2 SD SAN FRAN CA - 477 6431 From .81 CONCORD CA Calling Card Nov 3 115P 2 SD SAN FRAN CA - 362 7269 From .81 CONCORD CA Calling Card 6 357 SP47 4156717312546 N 7 6020A 94521 CR24 167 9053 3385 - - - 73 fr=qd S PHARMACY 5100 CLAYTON NO., CONCORD, CA 94520 (415)$27-9295 NOV $7._198 Date Patle •5 PpA�� Phone 1h7�L' 1 AU L 1nL�LG1. c,VB.Hi 4 00 AYTONN�CYCO 827-9295 HOURS IF NEEDED FOR PAIN DOCt 303E35 DR JACOBSEN TORS CATHY GRAING,ER HYDROCODONE/APAP 5/`00 30 TAKE 1 TO 2 TABLETS I1_27-88 10-90 GENERIX DL HOURS IF NEEDED FOR FAINY 4 DISCARD AFTER RX I (" MAY CAUSE DROWSINESS HYDROCODONE/AFAFI NO ALCOHOL 5/500 2_ DISCARD AFTER GENERIX SM i E PLEASE READ THE ABOVE DRUG INFORMATION AUSE DROWSINESS i RX 'MAY C NO ALCOHOL 1802 ALICANTE CT 672 7312 LAST FILLED ON 11-17-88 0 CALL IN ADVANCE FOR REFILLS RX PLEasE READ THE aeOVE DRUG INFORMATION THANK YOU FOR YOUR PATRONAGE 1802 ALICANTE CT 672731`2 $ 9.10 182-1765- 1 LAST FILLED ON DR MUST OR REFILLS. ALLOW TIME CALL IN ADVANCE FOR REFILLS 0 Order Total S THANE; YOU FOR YOUR PATRONAGE ----- -- -- S Save This Receipt For Tax and Insurance Records. 8.25 182-1765- 1 s IF YOU LIKED OUR SERVICE, IF YOU LIKED OUR SERVICE, PLEASE TELL YOUR FRIENDS! frmu4ms PLEASE TELL YOUR FRIENDS! fWauj �� THANK YOU FOR SHOPPING THANK YOU FOR SHOPPING C svaco I oa •< o � sr " arv. o K v c -! a -i nL 3 z r ►� ►� > vu ov ¢�•cCfA�LN vH "►• x H r crOies 0 am • :� Sv, � v -� • .pro ? � cvx d •- � � . _� ; 171 m O M.MZ v, v70O I o� til O -. = zee '' a I W. Pj I = t=7 •vr onL r .♦ r -4mwLn :I>. , w � O O H r 70 L" 1" 7 a � E x r N I-I o 4 41 3 �] 6n v,10 4011 14 r 3I ZI r 0 3 0 a s Uj 0 e CL , JfrRu4Ws' PHARMACY 5100 CLAYTON RD., CONCORD, CA 94520 (415)827.9295 PHARMACY 827 9295 f1merys 5100 CLAYTON BLVD., CONCORD, CA.. . 302992 DR NOTTINGHAM PA CATHY GRAINGER 11-11-88 TAKE 1 TO 2 TABLETS EVERY 4 HOURS IF NEEDED FOR PAIN HYDROCODONE/APAP 5/500 30 9-90 GENERIX DL DISCARD AFTER MAY CAUSE DROWSINESS J: ,- _ PLEASE READ THE ABOVE DRUG INFORMATION ''--- 1802 ALICANTE CT 672 7312 CALL IN ADVANCE FOR REFILLS - - - THANK YOU FOR YOUR PATRONAGE _ S 9.10 182-1765- 1 DR MUST OR REFILLS, ALLOW TIME Order Total $ Save This Receipt For Tax and Insurance Records. CT—_ J. . IF YOU LIKED OUR SERVICE, PLEASE TELL YOUR FRIENDS! rwifs THANK YOU FOR SHOPPING t HAPPY HOLIDAYS FROM SAFEWAY. f YOUR SPECIAL PLACE TO SHOP.931 PHILLIPS MOM 2,19 T TAX BALANCE DUE 3.18 CASH TENDER 3.18 CHANGE DUE .00 11/22/88 21:37 LANE 7 202 s 'Fool) R)W) PR rr : t:tt*`TL7N RD, �a '',•'tai _ d.`:PM '�',�Tyt��RE 48003, Q i 4 w .,n��G7 Ste. OPR 'TC�003, ��- O&W VAAW J*t&,j i o, { "M YQNACIO VALLEY BLVD,#C CONCORD,CA 94 521 PHONE 672.0646 t GRAINGER, CATHY � 1 14B 1 4 1802 ALICANTE DR ' CONCORD, CA" 94521 - 2: V*� ' ' NOTTINGHAM, 16R-404D F..Pr 15 Ps REG Loa,*,•UNL ._-PRICE $15. 05 -t #40 VIGODIN TABLET . . . (KN) ;r:. .. • • NDC#00044 _Oa- EDS 5 5TOF"F REG # ZKO19537 `. F,'PT 15 MS REQ; Lr'1r'F;: 7t1,tL UNL OD-,'ED FRMS'F0,11ri PW-., t?P IP 510 �•L.RT'; 11 Pn ?�77!,:`27 2: 2.5Fp1 STORE 4 39 RF_sa 15 OF41300,-7UN YGNACIO VALLEY BLVD,#C CONCORD,CA 94521 PHONE 6724646 If 71 ji F:=OL 14F'RP T,' _ .. 12/09/88 R>c# Mi 1 1 eiE3"? C.TT•:fQY BON ^57 69 T ' GRAINGER, CATHY TOTRL 15 .lam' 1802 ALICANTE DR C EN TEN() 20. cit.. • • CONCORD, CA 94521 URTOTRL 15 2S 40TTINGHAM, -DR MD • 'PRICE $7. 70 4, 5S CHRUGE • `.5 VICODIN •TABLET PEST H L I PRT` 1.11 NE'F r (KN) C4#00044-0727-02 EAS 3 # ZKO19537 oo co cc, t* C] C7 -A O .- CC3 irc cr� %ice y C7 p z =J r. C+ Ic 7 tti Si x 3 !y jVall, 4 O S o w ttwr RNa ; ` a t Q2AINGF�2CATHERM HOME 415—Ei72�7��7 1802 Alicante Court BUS. 415-395-55q� Concord, CA 94521 EMPLOYER S&lf-!GApbiV-g nPAignPr SEND BILI.TO Patient Qp } yy du111u1 Aug SOP OCt Nov De PAUL B. NOTTINGHAM, M.D. ORTHOPEDIC SURGERY 2222 EAST STREET, SUITE 305 CONCORD, CALIFORNIA 84520 - i (415) 676-1209 Statement To: Catherine Grainger 1802 Alicante Court ConcordsCA 94521 For Patient: DOB: 09-30-55 SS#: 546-15-5587 .AL. FWD. -'O- —j— FAMILY CREDITS CURRENT DyA�T[ MEMSER 09SCRI/r10H CHARGE PAYMUNTs ADJ. BALANCE I RI• amG YAO 50 DATE T CODE DESCRIPTION AMOUNT 11-05-68 D KAPLAN, M.D. ,INC 73564.26 KNEE COMPLETE 27.00 I HOURSRE FROM 9:00-12:00 & 1:00-4:30 ACCOUNT NUMBER DATE OF STATEMENT AMOUNT PAID PAYMENTS AFTER THIS TOUR NEXT STATEMENT27.00 7 PATIENT NAME HAVE YOUR HEARD FROM YOUR INSURANCE CO? ME HAVEN'T. PLEASE SEND US THE BALANCE DUE TODAY. , CATHERINE GRAINGER THIS REMAINS YOUR RESPONSIBILILTY. MAKE CHECKS PAYABLE TO: DIABLO VALLEY RADIOLOGY MED GRP Tax Id 94-1235894 L J£ROME LEWIS NO INC PAUL E MORRIS NO APC place of service: HT OIABLO HOSPITAL 1/P RONALD A WEINTRAUB NO APC HOWARD E COHEN ND INC Referring Doctor: NOTTINGHAM P DANIEL KAPLAN ND INC -DAVID YIRSON ND INC Diegnosit: 023.80 RICHARD SAYRE MD PC JACOB E►STEIN NO INC ROBERT A CLARK MD INC COWARD MILLER MO INC OIABLO VALLEY RADIOLOGY MED CRP RICHARD M SIGEL NO INC ISILLiAN NOOOICK NO P.O. '+BOx 5016 SAN RAMON CA 44393 _ 415/86#-iO3 a SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION DATF Con DESCRIPTION AMOUNT 16-29-88 DONALID 'COHEN, M.D. 73560.26 KNEE LIMITED 20.00 10-29-88 DONALD !COHEN. N.D. 73564.26 KNEE COMPLETE 27.00 i ntig nFFTcF HOURS ARE FROM 9:00 12-0 A 100-4: ACCOUNT NUMBER DATE OF STATEMENT AMOUNT PAID + + PAYMENTS AFTER THIS DATE WILL APPEAR ON 12-19-1119 OUR NEXT STATEMENT PATIENT NAME HAVE YOUR HEARD FROM YOUR INSURANCE CO? ME HAVEN'T. PLEASE SENO US THE BALANCE DUE TODAY. THIS REMAINS YOUR RESPONSIBILILTY. HAKE CHECKS PAYABLE TO: DIABLO VALLEY RADIOLOGY MED GRP Tax Id 94-1235894 L JEROME LEWIS ND INC PAUL E MORRIS NO APC Place of service: MT DIABLO HOSPITAL I/P RONALD A WEINTRAUB NO APC HOWARD E COVEN NO INC Rafarrin8 Doctor: SARACHEK MD DANIEL KAPLAN ND INC DAVID WIXSON NO INC Diagnosis: 718.86 RICHARD SAYRE MD ►C JACOB E►STEIN MD INC ROBERT A CLARK MD INC EDWARD MILLER NO INC DIABLO VALLEY RADIOLOGY NED ORP RICHARD N SIGEL NO INC WILLIAM HOODICK• NO P.O. sox $016 SAN RAMON CA 94383 413/866-8433 SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION f 5. Ross 4027902 976655-1 DR . NOTTINGHAM1 /13/gg D�c55 LESS KATHY 37hAINJER 3 755332 Mi ONE TABLET Tri REE SAVINGS COME IN ALL SIZES TIMES A DAY "TENERIC MOTRIN ,T� - S �af::: � •�.- h., - .. r _ IEUPROFFN 600MG BOOTS 30 $ 9. 97 WTM OYY MCK sr c%*arP17r CALL REFILLS 1 DAY IN ALV Ak F C U S T M _ E R C 57EE56-1 DR. NOZ T I irG RAr; 1/13;'6 0 n,ATHY GRAINGER F TAKE ONE TALLzT EVIRY 3-4 Y HU SE 4S NEEDEI1 FUR PhIN GENERIC VICODiN APAP/HYDROCODONE Thr SARA i5 7.56 Yi IM YOI MCK :�_..... 555-03E5-64 CALL R ,FILLS 1 DtiY IN iL4-AiNLa TRANS. TOTAL t gMER S16NATURE L � 1 D . C=) i ' ��0 t•; m .c r CL f Z { Issci x" �► ti T * rV ►.-.r �._., i N W Y The issuer o1 the omd irlentlfied,on'th"m s authonzed to DBY the artnurrt * •^- �' �% !-- :s `n a e ( ('• (- shown as TO1l4L popgr p nj 6kanise m pay such TOTAL i yYtth tVgiergsddGe ttlnreoni subject to and in accordance G vz ♦ C cc w hg adreBrten pore .,tha use of each card. IT. I WENT�FICATION C A. T), Tr:•: { CG T;:G TL ST ATURE roDE #IDSE RECD BY: 8092 2-88 -CQ � xr�i,` ! iRivious 01, };.., r.. •IALANC[ NAM[ r 4 H ,.. i; ^a'+,,;tr yY�.r.�(' '.t�!•:,Y�r� iPrk ----'�rae`'-...J 4.,�r�'. ±5 4,^:r?��;iiC�.O•.ili;:.�q.:,•Cws.rT•,f;•ry�' ATTENDING PHYSICIAN'S STATEMENT 1974 California Standard Nornandauire D D/C Om of Service �� o �A OFFICE SERVICES NEW ESTAB FEE ©CONSULTATION Office Hosp FEE WN of Injury / / Brief 90000 Limited ( ) ( ) 90600 [E]ER Limited 90010 90060 Extensive ( ) ( ) 90610 Intermediate 90015 Comp.H&P ( ) ( ) 90620 Follow-Up 90050 By Report 90630 Extended Re-Exam 90070 Seen• Request of: Non-Cancelled Appt. 99049 0 OTHER SERVICES CODE FEE J❑HOSPITAL VISITS Initial Subseq FEE [ INJECTIONS Brief or Limited 90200 Inleetlon/Malor Intermediate 90215 Injection/Minor r Comprehensive 90220 Aspiration •Visits • 90250 Admit_/ /Discharge_/ �G MATERIALS C CASTS Under 10 Over 10 Detention time 99040 Long Arm 29060 29065 99070 ©SURGERY CODE FEE Short Arm 29070 29073 Cylinder 29360 29365 Long Leg 29340 29345 Short Leg,Walking 29420 29425 Short Leg 29400 29405 10 SPLINTS OM X-RAYS: Long oo v�Arm 29100 29105 Snort Arm 29120 29125 f` Long Leg 29500 29305 r - Short Log 29510 29515 Pleaib af(at6(611 Cg p others: 1 boo10r latoraaee forraanA aE1611 to loor Intaranee DIAGNOSIS: TOTAL FEE 3�- Please Retain Pink Copy For Your Personal Financial Records. Attach Yellow Copy To Your Insurance Form and Process For Benefits. AUTHORIZATION TO PAY BENEFITS TO PHYSICIAN: 1 hereby certify the above named services were S S N#5 5 4—7 0—2 81 7 rendered and direct that payments be made to the physician named hereon. 1 understand 1 am financially CA LIC#G 04 6 0 2 responsible for charges not covered by my Insurance. PAUL B. NOTTINGHAM, M.D. Signed - Date ORTHOPEDIC SURGERY Insurance Carriers— This form has been adopted to keep paper work costs down. If any additional forms 2222 EAST STREET, SUITE 305 or itemized tills are required they will be completed upon the receipt of 615.00. NEXT A.M. CONCORD, CALIFORNIA 94520 RETURN: ys Weeks__ Months APPT. P.M. (415) 676-1209 Day Month Date Time i I 1026 Oak Grove, Suite 4v4 Concord,California (HittenbergersTelephone (415) 671-7771 1902SINCE I N V O I C E TO: DAN GRANGER FROM: HITTENBERGERS 6040 GREENARMS DRIVE 1026 OAK GROVE #4 OAKLAND, CALIFORNIA, 94611 CONCORD, CALIF., 94518 ATT. ERIC GREEN DATE OF SERVICE DESCRIPTION COST 12-6-88 REPLACE FLEXIBLE INNER SOCKET $600.00 12-6-88 ADDITION TO LOWER EXTREMITY SUCTION SUSPENSION $139.00 12-6-88 REFINISH FLEX. FOOT PROSTHESIS 3HRS. TECHNICIAN @ 45.00 P/HR. $135.00 TOTAL DUE $874.00 �nwwio h • 11 w.n.uc IG CERTIFIED BY THE AMERICAN BOARD FOR CERTIFICATION IN PROSTHETICS AND ORTHOTICS 4- 4�. FORM APPROVED OMB NO 0938-0008 PLEASE-DO NOi _. 'STAPLE IN THIS AREA HEALTH INSURANCE CLAIM FORM (CHECK APPLICABLE PROGRAM BLOCK BELOW) Lj MEDICARE MEDICAID C.A.PU$ CHAMPVA FECA BLACK LUNG OTHER MEDICARE DICARENO) NO 1 )MEDICAID N0.1 (SPONSOR'$$$N) IPA FILE NO 1 - ISSN( '(CERTIFICATE$SNI PATIENT AND INSURED (SUBSCRIBER) INFORMATION 1.PATIENT'S NAME(LAST NAME.FIRST NAME.MIDDLE INITIAL) ' 2.PATIENTS DATE OF BIRTH 3.INSURED'S NAME(LAST NAME.FIRST-NAME.MIDDLE INITIAL) GRA TN(;EP CATHERINE 09 30 1 55 GRAINGER , -_DANIEL s.PATIENT'S ADDRESS(STREET.CITY.STAVE.LIP CODE) 5.PATIENT-8 SEX ,6.INSURED'S 10 NO.(FOR PROGRAM CHECKED ABOVE.INCLUDE ALL LETTERS)) p F� - 1,802 ALICANTE COLIPT MALE❑ •FEMALE 526568605 rnNcopn rA 94521 7.PATIENT'S RELATIONSHIP TO INSURED S.INSURED'S GROUP NO.(OR GROUP NAME OR FECA CLAIM NO) SELF 'SPOUSE CHILD OTHER 65978 , 672-7 12 0 E [D ❑ E INSURE p IS LA AND COVERED BY EMPLOYER HEALTHB.OTHER HEALTH INSURANCE COVERAGE(ENTER NAME OR POLICYHOLDER 10.WAS CONDITION RELATED TO I I�LU ^'J FRES'(ST BTfl.k.Sf3REWtLMC AND PLAN NAME AND ADDRESS AND POLICY OR M EOICAL L ^��G 1 ``44 lTlI LL••,, G ASSISTANCE NUMBER) A,PATIENT'S EMPLOYMENT YES F-] X❑. NO - TELEPHONE No-672-7312 B.ACCIDENT tt.a. CHAMPUS SPONSOR'S ACTIVE BRANCH OF SERVICE AUTO .X❑. OTHER i O DUTY Q DECEASED STATUS ; RETIRED . 12.PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE IREAD BACK BEFORE SIGNING) 13./.AUTHORIZE PAYMENT OFAIEOICAL BENEFITS TO UNDERSIGNED PHYSICIAN OR SUPPLIER FOR SERVICE'DESCRIBED BELOW I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM I ALSO REOUEST - PAYMENT OF GOVERNMENT BENEFITS EITHER TO MYSELF OR TO THE PARTY WHO ACCEPTS ASSIGNMENT BELOW " SIGNED SIGNATURE nN. FILE DATE SIGNED(INSURED 011 AUTHORIZED PERSON) PHYSICIAN OR SUPPLIER INFORMATION 14 DATE OF: ILLNESS(FIRST SYMPTOM)OR INJURY 15.DATE FIRST CONSULTED YOU FOR THIS 16.IF PATIENT HAS HAD S ME Oij. 'Icx.IF EMERGENCY (ACCIDENT)OR PREGNANCY.ILMP) CONDITION SIMIIAR,ILLNESSOR1 _OILY. .11E.DATES CHECK HERE 17.DATE PATIENT ABLE TO 16 DATES OF TOTAL DISABILITY DATES OF PARTIAL DISABILIry RETURN TO WORK ' FROM ITHROUGH FROM f THROUGH 19.NAME OF REFERRING PHYSICIAN OR OTHER SOURCE(e,9-PUBLIC HEALTH AGENCY) 20.FOR SERVICES RELATE[TO HOSPITALIZATION GIVE HOSPITALIZATION DATE P NOTTINGHAM � ADMITTED 1 L>'/L _ /I I .DISCHARGED 21.NAME A ADDRESS OF FACILITY WHERE SERVICES RENDERED(IF OTHER THAN HOME OR OFFICE( 22..WAS LABORATORY WORK PERFORMED OUTSIDE YOUR OFFICE' M.T - DIABLO HOSPITAL IN PT YESfl--OCHARGES 0 . 00 23.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY.RELATE DIAGNOSIS TO PROCEDURE M COLUMN D BY REFERENCE NUMBERS 1,2.3.ETC.OR DX CODE e. 1, - EPSDT _YES r No 2' FAMILY PL"AIJNING� YES El ❑NO t' 3. ------------------------------------- .. PRIOR 4. AUTHORIZATION NO. 2!. A C EA FULLY DESCRIBE PROCEDURES.MEDICAL SERVICES OR SUPPLIES DE�'• F G' H LVE BLANK DAY 'OF SERVICE PLACE FURNISHED FOR EACH DATE GIVEN .DAYS t :: RV PROCEDURE CODE (EXPLAIN UNUSUAL SERVICES OR CIRCUMSTANCES) DIAGNOSIS -OR T.O.S. -- ' FROM TO SERVICE-(IDENTIFY: 1. _ CODE CrAROES._- UNITS _ 102486 1 27536-34 OPEN RED . INT . _FX 6-50 i.00 1_ A... RIGHT TIBIAL PLATEAU 0001.4 4 ANESTHES1A TIME`,._ 3 H6vRG 20 MINI "It MODIFIER 34 EXPLAINED. ,.�.;..- 3'4-=.-EMER�EN,C':�' WITH TUBE . ..;. 4..._ �.. 25.SIGNATURE OF PHYSICIAN OR SUPPLIER(INCLUDING DEGREE(S) 26.ACCEPT ASSIGNMENT(G -NT 27..TOTAL CHARGE (. ZB.AMOW17 PAID 1 29.IBALANCE DUE OR CREDENTIALS)(1 CERTIFY THAT THE STATEMENTS ON THE CLAIMS ONLY)(SEE BAC,KI _ REVERSE APPLY TO THIS BILL AND ARE MADE A PART THEREOF( ?�.'•• -?'III,;,;�,I, �' ,!ter^,it."I i 3;1i 684 1�E8 y -'�,.''',1f NO•% 1_ 31.P"VSICIAN'S SUPPLIERS AND OA G AD SS.ZfF �' ~' -+�J -'�'•, CDE ANO TELEPHONE NO. �r t+'w -) '" ' - t 3o.YOUR SOCIAL SECURITY NO:1;._Toe, - , ROBERT. J .o-SETOIJVr�111,.-0, INC,: 2299 BA(-OTh 12/08/88 'CON CORPi:ji::IT9TT..R-lT 4!�S•V C�fYµ?5,G!.G,', . 32.YOUR PATIENTS ACCOUNT NO 3RAC764292 C018DC INFR. .00. IRS 9.4-234"'8`94'7'_ ' y. ,D,,D. . 0.0C2212:91t3'F''°?'rEai( -PLACE OF SERVICE AND TYPE OF SERVICE(T.O.S.)CODES ON BACK •'ApPROVED`B�"q>itA�COUNCIL' " FORM HCFA-3• tY-Bq OAW WCP-ISOO REMARKSMEDIfAI,W_vlC86/83 - v FORM CHAMPUS-501(124)iQFO. n" 0D.r�gYT- -g•:• _. _ FORM AMA OP-OW � � w s. co 9=17y 01 .4 tr-v 90,4 im p to r+ s = � N i s vo 7� � N p3 2 i y o G s o :v 9` C ems' 0 0 cn ;� � Ysy } i c•'',� © G s © `pi cr, 2 Nt?�o � Z70N d v `n ";l-, w $ Ho � vz' gN� . o .•G cr. co M 4 w ct rl s 'r/ O w 6 C Q.1 Ito op CO N dry T -dVS-6 a roc � � c', t � � � 'Q`� � 3 •- � �� N� o .G m co tP co rt+ 3 Cow .• f� N 7g,s , kA S, s rr; -� ) .I s .�,• fs �4 .a• yr MERCHANDISE NOT RETURNABLE Hit ergers OAK GROVE MEDICAL CENTER DELNERY 1026 OAK GROVE RD.SUITE 4 SURGICAL AND ORTHOPEDIC APPumcaa CONCORD,CA 94518(415)671.7771 !LEASE PWl T: D R q. US ER NO EMPLOYED BY EPEAT SOLDIBY CREDIT CAH .O. ORDER DATE FITTING OATS ATO FINISH DATE RELIVE E �l�B. DEPT ACCT. CODE OTT. DESCRIPTION /RICE tee SIGNATURE oAaH RECD H � 16795 O� MERCHANDISE NOT RETURNABLE OAK GROVE MEDICAL CENTER DELIVERY 1026 OAK GROVE RD.SUITE 4 SURGICAL AND ORTHOPEDIC APPLIANCES CONCORD,CA 94518(415)671.7771 PLEASE PRINT: 3 O % L F D R O �� ��y sa►�-� R. USTOME N EI/.PLOYED SY EPEA CREDITBOLD my HI N I L � O /iZO.� Osn Accv cow ow. OEECRIRION PRICE o? Kjo SIGNATURE ICASH RICZ WITH opmem 84 16823 PATIENT NAME DIABLO VALLEY RADIOLOGY MED GRP CATHERINE GRAINGER P.O. BOX 5016 SAN RAMON CA 94583 ACCOUNT NUMBER STATEMENT DATE 1072396 11-28-86 fORWARD11119 AND ADDRESS CORRECTION REQUESTED 7640-119 AMOUNT PAID !loco of Service : NT DIABLO NDSPITAL I/► 27.00 SAMC�10�1072396 CATHERINE GRAINGER 1802 ALICANTE CT DIABLO VALLEY RADIOLOGY MED GRP CONCORD CA 94521 P.O. BOX 5016 SAN RAMON CA 94583 Billing questions? Call : 415/866-8435 PLEASE DETACH AND RETURN TOP PORTION 'WITH PAYMENT DATE DOCTOR CODE DESCRIPTION A14OUNT 11-05-88 0 KAPLAN. M.O. ,INC 73564.26 KNEE COMPLETE 27.00 OUR OFFICE HOURS ARE FROM 9:00—L2:00 — ACCOUNT NUMBER DATE OF STATEMENT AMOUNT PAID PAYMENTS AFTER THIS 1072396 11-28-88 YOURNIEXXTLL STATEMENT 27.00 PATIENT NAME ;AN INSURANCE -CLAIN IFORM HAS`OPEN ftLED HOWEVER. THIS SAL ANCE gEMAINS YQUR �1�i;' T rM. PLEASE CATHERINE GRAINGER EMIT PAYMENT .-TODAY.,{ NAKE CNECKS PATABLE OIABLO VALLEY .#tADIOLQGY DIED 4RP �r 4kx A 3ERONE LEWIS 00 INC ' AU1 B10RRIi MIO a)PC ► soli i1f� l � j�77AL r /1 RONALD A 1<EINTRAUB ND A►CDI/ARD # `1:DN[S) N9 3BCi'fNR>F `R# 8a1o� � DANIEL KAlLAN 11D ItICfATraD irtlrfOND 1NC � RICNARO RiY![ SAD !C �{, s�Af.OR I ?EYM:IID iii Si-MR- 1141;p.' *" � � r �OBCRT A CLARK i10 I�IC *a ; DI1�Rp ;L ]a C R ., # -4 a� ,r a � ' c S DICNARO N i#its �ID'I#t _1`7 SIA �N) i1 0bz «��1D ;Y� I `A a .. r £yF ,F`a , 6. z envy s J y 'F " •' °•i r .. u• F` `"f ti `�,+� •• ,6 r .5tr4.'1'-E ,.x{ M`j t„is�C 111�'t �7! � ,,ix ? '.,. 'S `'"^'1' `.€x..ty.`�.``,},_ �'Qat�� -�,"��.K,�,, s frz y •_T ., n���i`. <s:, �a �`�iak'�. .. w .:tJ.fi.4' .:.Y.r:....._��-�d..a5"..�. .G:.- t�::�'. •.t.. 'au ... _... .sS""�'�� �' _ ''""at�hR�.` �.aa, _ _.. SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION . PATIENT NAME DIABLO VALLEY RADIOLOGY MED GRP *' CATHERINE GRAINGER P.O. BOX 5016 SAN RAMON CA 94583 AUNT NUMBER STATEMENT DATE 1070906 11-28-68 tDRiARDINC AND ADOBES$ #ZRRRtCTI-ON RE "STED 7#40-709 • AMOUNT PAID P1aC6 Of tOrvice : NT DIASLO HOSPITAL I/P 47.00 SANC*1001070908 CATHERINE GRAINGER 1802 ALICANTE CT DIABLO VALLEY RADIOLOGY MED GRP CONCORD CA 94521 P.O. BOX 5016 SAN RAMON CA 94583 Billing questions? Call : 415/866-8435 PLEASE DETACH AND RETURN TOP PORTION WITH PAYMENT DATE DOCTOR CODE DESCRIPTION 10-29-68 DONALD COHEN, N.D. 73560.26 KNEE LIMITED 20.00 10-29-88 DONALD COHEN. N.D. 73564.26 KNEE COMPLETE 27.00 OUR OFFICE HOURS ARE FROM 9:0 2tQQ & IrOO-4:AQ ACCOUNT NUMBER DATE OF STATERtENT AMOUNT PAID PAYMENTS AFTER THIS DATE 1070906 11-28-88 OURNIE))fTLL STATEMENT PATIENT NAME AN :INSURANCE 'CLAIM FDRN' HAS `BEEN ..FILED HOWEVER, 'HIS 1ALANCE REMAINS YOUR OBLIGATION. PLEASE NIL CATHERINE GRAINGER EMIT P.AYIIENT ?OOAY. MAKE CNtCKS FAY#slt To: {` DIABLO VALLEY RADIOLOGY JWD tRO L atRONE tevis eo illc �►a.vt t iI�la=$ +ID ate ►'ls�� � I►! 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APPROVED OMB wo 0938m79 sac In Nov NO CA T77 Go 1 0^71 JCD I[An JCO I DATE GATE co DATE w FROM rMAOUGA CA. .7 VALUE Ass�49 VALUE JCD -CO12VTAEK CONVERSION 251.81 IABOILATORY OR (LU) 300 DX X RAY 604.35 320 OR SERVICES 360 3160.77 -RESPIRATORY SVC 410 4.61 L"ERGENCY KOON, 450 276.70 57 PAVIER 8D DEDUCTOLIE C 004NSURANCE 42 EST.RESPON3414.11TY 63 PRIOR PAYh0ENT5 66 EST.AMI DUE DUE FROM PATIENT 1111- 26 IMSURED 5 NAME IN. 70 06SURANCE GROUP NO IfEnOPOILITAN GE SAN FWCISCO, CA. NOTICE TO The hospital is acting solely as an agent for the patient in filing for insurance benefits THE PATIENT assigned to it howmr.the hospital can assume no responsiNlity for guaranteeing payrnent of om Brad charges as Show on the two of the bill.Credit is showi only who the hospital fies actually received payment.Should an overpayment be made,a refund w co will be sent to the authorized party that Is due the overpayment. US'N*HCFA'vwW PATIENT COPY rp A-cl MT K-ilk. 13LO H---"SFI rlE-�-? �--ENT:-:-R F.0 X" 4 4-2 6 1 bF BIL` 'bATE D..OOF BILL BAN 9414-" CLE 10'3; BE I 415 67,q MT.a DIABLO HOSPITAL MEDICAL CENTER 2540 EAST ST. CONCORD, CALIF.94520 6 OPERATED BY THE MY. DIABLO HOSPITAL DISTRICT S PATIENT NAME =�--PATIENT NUMBER ISEX I I ADMISSION DATE DISCHARGE DATE DAYS :'b40 � i 3 3 1 1O:-.:-7 i om INSURANCE COMPANY rRoup No. LIAN'i=-&- G, 101 5"2656ef-*- 6'&-)= 18(')-* ALICAi,'l - C-i" CONCE,0RD-, Cf:. 94t*.-*l P-:L*-JT7JNGH-'�N- P MD DETACH HERE AND RETURN TOP PORTION WITH YOUR REMITTANCE TO"INSURE PROPER CREDIT • SERVICE TOTAL EST. COVERAGE EST.COVERAGE EST.COVERAGE EST. COVERAGE E ATE OF DESCRIPTION OF STWATEC, PA-.; ERVICE HOSPITAL SERVICES CODE CHARGES INS CO. NO, 1 INS. CO. NO. 2 INS-CO. NO. 3 INS. CO. NO. 4 AMOUNT I r Z7. �'jl 11 T C' .11 L 0, -'E T C:H \0 I cliji I F;Er'E C--- I I T FIR -' . H; ' F -7- 1 5"J. -)I AL 1 1'2 H: f, C0 Di'i ' TL B8. 9- P7 1 t!1 . 20 4 4000C;1 15 1 -Z'fo .;4C)0 30 1 7C, 3()1 7 20. S4 f, '7 F. A 6 4601 imr.1 4 6 0 3 59 o 4.58 0 1. F'Ari f= SI O -E 4 6 05--5 Q I lo. 11. C' - &- 4. 76 41 NASAL 4606050 A. 7 1JELCO-1 4608 6. 66 ..3 6.66 -50 1 C I R'-,--'1-1 SR,7H 0 460965-1 Ci� 14. 97 14. 97 I D R-ir,! IOBAN 66 46133Z;J 31. 64 3' . 64 4 6 13 7 2`9 7 0011 E'Rf'A!:-'E C ARM X" 19.eli. 19. alb 18. 34 1C. 3 ()f- I DRSNtl )'E r-,,0 5 X 4614:.50 3. 95 :5. 9t 0C>1 IV 5r W.1 0 4617560 3. E32 3.82 0-)I k ArEit-1*;'.SS 1 ON 46175: 10. 34 10. 34 i ' IT IT -42.83 -r7 r- 4 6 17 9 f 00 W'ATFR SE 2.83 F, -45 -7 C,,, 1 T NL E.., 50 -161 G* 7. 77 4 6 181 12. 114 1'. 14 00 1 V I T LTA 001 riAS-" ANES OH'.10 4616450 12. 5e 121.58 -0 4 6 1 9'�" .:.-9 001 F,AC'P;.' M I N'OF: 9. 92 -)3PAC-" G C.i t;!t 4619:'-: 1 1 . ? I I . 0-1' 7 --, 00 1 PAC'r' EX T F:,E.r1l 1 T Y 4619'?�- -Z 1: .. Q GT !-a. 9.2 004PAD.06 CA IA . 0011FArl DF-1C-/EGG* CR -'46:21 J:;54.? .2' 5:7; 00 1 PAD PRE' -et 621,:5':% 3. 69 3. 69 PATIENT NUMBER PATIENT AMOUNT IS DUF WITHIN :0 DAYS OF THI'. STA71f.'iN-, DATi. ADDOfONAI, PA7?t1,*l 6!ttING MAY BE REOL)I RED BE-AU51 OF CHARGES REFERRil, 1C1 1,41 BU SINES`` OFFICE AIIER TH;:, P:L! WAS PREPAREr'OF BECAUSE INSURANCE COVERAGE DIFFERED FA01, '-U�ESTIMATE PLEASE RETAIN THIS STATEMENT FOP INCO.mE TAX PIJRFOS[S HCS- FED. TAX NO. 94-60038."W PATHOLOGISTS RADIOLOGISTS NEPHROLOGISTS FLECTIONYSTAGRAPHY FOR LABORATORY SERVICE DESCRIPTION PROCEEDED BY A LETTER. SEE F. HIIN7 .D DI:.'to m P. VERIAL c J HARRIS, M.D. M A6�'I M.k, Fr, �- REVERSE SIDE OF BILL FOR IDENTIFICATION OF REFERENCE LABS. ')":):OGI t.�:D!'A, GROUP 1. WE I S< MD D TROX '"'C"AR ADIATION ONCOLOGY P FANG M.D ELECTROMYOGRAPHY E) BEtRoNt %' � �ARMIEI M.D R. SEIBEN, M.D MT DIABL.0 HCSF NIETECENT F: PAGE vo: DATE OF P.O. SOY 44261 E 'E OF BILDATE OF Blll PRF\ BI:'. SAN FRANCIS-CO, CG. 94144 :,Ff-:LF 10113i /sol I 415 674--2:�.102' MT. DIABLO HOSPITAL MEDICAL CENTER '± 2540 EAST ST. CONCORD,CALIF.94520 b.• OPERATED BY THE MT.DIABLO HOSPITAL DISTRICT PATIENT NAME PATIENT NUMBER ISEXI ADMISSION DATE DISCHARGE DATE DABS 3;3';I NF2F-R CATHF:FI'I Pf 1061'c•404511 FI 3:', I Q �4/rsP1 GUARANTOR t'.' INSURANCE COMPANY GROUP Nom. ow L AN 1 CL. =CAH T:.��'G'I. I 1 •_' t=•r•'��••_ 401 55.26568 YT L till t`.f�i t.._ 180:_ P L.I C ANTE C'T: CONCO,n11, CF': DETACH HERE AND RETURN TOP PORTION WITH YOUR REMITTANCE TO INSURE PROPER CREDIT ATE OF DESCRIPTION OF SERVICE TOTAL EST. COVERAGE EST. COVERAGE EST. COVERAGE EST, COVERAGE ESTIMATED PATIE!,; ERVICE HOSPITAL SERVICES CODE CHARGES INS CO. NO. 1 INS.CO. NO. 2 INS. CO. NO. 3 INS.CO. NO. A AMOUNT _ t"ICl7F'`Iv ��: _. . t.l�::c(�: T rlt^._`1`�i_'_ •..� 3_ •_; _. cC� 'J C ... . IJ(1i>E r'L_. .1 !.P'_.Fr-_ 624'- 5,.i• 7;.TAFIF L.7-F' FK , 46226 : 1f �-t. _ .._. 34 0"._TUFF: CCl�''.i';Ei;T 6 `+_3:T` . _.. 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CIU IHEMOCRA"', 50350 `' 20. 25 203.•25 o 1 ,-. ;;:�• UU I P0T(ASS 1I1p1 5(114.'i 4::' �: . 4:' 2-x_':. 477 C)c)IFt01'(r-1e1f_. . S0I A ..4:0. C..47 "_'s 47 :, E. �... 00 18 O T U^! '.a014. 2r:. +r ..._.. 4 o ^.•F. 50 � Cr a 1 2 7 E1,'.. r CIc:I�TAT CFtAirE :306 ,•:1�:� i,-r , C,) PATIENT NUMBER PATIENT AMOUNT IS DUE WITHIN 10 DAYS OF THIS STATERCEfJT DATE. ADDiTiONA: PATIENT BIILINC- MAY BE RFOUIRED BECAUSE OF CHARGES REFERREC TO T-f BUSINESS OFFICE AFTER THIS BILL WAS PREPARED OR BECAUSE INSURANCE COVERAGE DIFFERED FROM OUR ESTIMATi PLEASE RETAIN THIS STATEMENT FOR INCOME TAX PURPOSES HOSP. FED. TAX NO. 94 6003847W PATHOLOGISTS RADIOLOGISTS NEPHROLOGISTS ELECTRONYSTAGRAPHY FOR LABORATORY SERVICE DESCRIPTION PROCEEDED BY A LETTER. SEE F. HL)NT M D DFABIO VALLEI R VEPTAL M.D 1 HARRIS. M.D. REVERSE SIDE OF BILL FOR IDENTIFICATION OF REFERENCE LABS. M Asti MD RADIOLOGY MEDICAI GROUP T. WEISS M.D D TRCxli MD RADIATION ONCOLOGY P. FANG M.D ELECTROMYOGRAPHY D BEER'IW, MD R. CARMEL.M.D R SEIBEN M.D MT DIASL1) HL'SF !i El- CEN E t-r. PAGE I,C OF slu` PATE OF enE pATF o+ F'.0- BOX 44'..-'_61 FRF' Bilt SAN FRANCISCO, CAS 441=j EJLF i0 31-' I 415 674— 14 MT. DIABLO HOSPITAL MEDICAL CENTER 2540 EAST ST.CONCORD,CALIF.94520 OPERATED BY THE MT. DIABLO HOSPITAL DISTRICT S PATIENT NAME PATIENT NUMBER ISEXI I ADMISSION. DATE DISCHARGE DATE DAYS ra?1JG _R Lt^IT}1 =.R I 1J 1 640.4;5 i . .3 1 o' �'9;'E;s GUARANTR . 00INSURANCE • _GROUP • ®� DAPJ_ tL z c—A 1 .:ER 1 . !•;_:U.", .iJC: 101 `265.60 1802' AL.I Citic, "E C COW: ORD CIA 945::1 DETACH HERE E RETURN TOP PORTION WITH YOUR REMITTANCE TO INSURE PROPERF ATE OF DESCRIPTION OF SERVICE TOTAL EST, COVERAGE EST.COVERAGE EST. COVERAGE EST. COVERAGE ESTIMATE: PATIENT OE OF DESCRIPTION OF —7 RVICE HOSPITAL SERVICES CODE CHARGES INS. CO. NO. 1 INS. CO. NO. 2 INS CO. NO. 3 INS. CO. NO. 4 AMOUNT C. .'FMD i.-xTt;ir;F-t 13 co . 1?•L', - - 1..5:_ J1. '�• i 6 i� (_•(_1'_lE:IC, 1:7 +_1.{i,t r_—/i:. 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A AMOUNT OF —11F'F,.: 3-FY r_ 4-6 -R4 9,1 _.'041%I+_% 604 _ ._tf 6C -i. -3t_ 5_r1. 17 = - . 17 41: _ 3 67 3 6 ' 4 1. 14 4. 61 •4. 61 LME.r, F;rli)!f `_':>4=3C! 138. 7'1 131x. 70 42,50 13S. CTF i71:'. U0 U-' E'.;;:.R. CHAR3ES 7864. 98 76&4. 98 LF;T_{ TL5'i S GJ ''H Ihd:.:_UIIC' T 17. 5!: i._AD SER'.,? :E C•HAF� .' 'E C T F+ L 7E't4. 96 70« 08 PATIENT NUMBER PATIENT AMOUNT 15 DUE WITHIN IC DAYS OF THI` STATEMENT DATE ADEI,TIONA! PA*IE1:T 61LIING M,A1' BF REQUIRED BECAUSE OF CHARGES REFERRED TO THE BUSINESS GFFICE ATTEl Tn15 Blu WAS T n IC;&..b40-451 PREPARFDORBECAUSE INSURANCE COVERAGE DIFFEREDFPOMOURESTIMATE PPY TH1S MMCJ:.: ;T 4)L: PLEASE RETAIN THIS STATEMENT FOR INCOME TAX PURPOSES. )SP. FED. TAX NO. 9a-60036a7W PATHOLOGISTSRADIOLOGISTS NEPHROLOGISTS ELECTRONYSTAGRAPHY $R'LAEDK*'fl3taER�E-IDESCOITIOBH'ROCMED BY A LETTER, SEE R. HUNT M.D D:o6.c IAF, R. VERTAE M.D. J. HARRIS, M.D. t ^y(.RIF S FC)R I�EN�JFLCATION Of REFERENCE LABS. M ABIE M.D RADI,_;oo-, '.EDICAL GROUP T WE ISS. MD. 'F'-•''E �1�'`1 �' - --T D TRO?.EL M.D RADIA Tt ON ONCOLOGY P FANG. M.D. ELECTROMYOGRAPHY C 6EEPLI.E n+.D F CARN'EL MD R. SEIBEN.M.D. f" t�. 1:1?:, ;r:!_•a ;'i I A-SE DFIACH AT PERFORAI ION AND RE TURN YOUR REM,,'.A PAGE 4 F; an_ IS( s CA 94 11 ;,j AMOUNT ENCLOSED TYPE FINAL PATIENT NnAME { I PPATIENT ACCOUNT NO. L ADMISSION DATE DISCHARGE DATE, BILLING DATE VI LJRIt.L iiyCP"ff IFi ,I NF* iHi C)L..-/J-'f�J��' GUARANTOR INSURANCE COVERAGE POLICY NUMBER i GRAINGER tDAN!Ci METROF'U�L. ITAN LIFE bZ6!56;1+_.C15=/7c 1 > AL I CANTr_ CCIJt:'i _ I C.urti,..'L-I(.D CA 94!�'_t � SERVICE DATE SVC.CODE DESCRIPTION CPT CODE OTY AMOUNT I �' :� SUId�'ir�Fi� !�'� SL-F:L`i�F: it•r� I i i EALANC FO►-;W AR- 1 7t_ _4.9 SEin-1 Ft :IV -,:t~I.'Rif-:0-_:).iFi P'-lAF,,it C?'Y {� I 79.05 I _ I DRUG' J ' I t' o i L t 1 T 1 111' 1:719 r S T'1 i1? 'E'1_i�.� Z 15.7c; HA1%:I';'L' iGY f-IAG 1 114.+-'1 I I `� - T It'1 '1 FL-1) St_ItiA:v'.:f_" D,!E I.TFE i i I I I i i i B15(8!88) 1-11 t)r'�o' 4C>45 TOTAL 1 INDICATE AMOUNT ENCLOSED AND RETURN TOP PORTION WITH FOUR REMITTANCE. TOTAL CREDITS Ci.CI{' INCLUDE PATIENT ACCOUNT NUMBER ON YOUR CHECK. TOTAL DUE I RETAIN BOTTOM PORTION FOR YOUR RECORDS. ESTIMATED INSURANCE COVERAGE 12-'15 9. 19 HOSP.FED.TAX NO.944003847 1 DR LABORATORY SERVICE DESCRIPTION PROCEEDED BY A LETTER,SEE EVERSE SIDE OF BILL FOR IDENTIFICATION OF REFERENCE LABS. ► (I (? 1 -------------------------- — --- ..fie ".`-I �.BLCI MrDIC:AL CEN-i Ei-%, L 'It FASL Df,1ACH Al PCHFORAItON AND RE I URN Wl I H YOUR REM I I 1ANCE Gox 4 '.'-*-1 PAGE .7 L-r:t Rr a r:c i s c o 9 CA 9.1.144 AMOUNT ENCLOSED TYPE FINAL INF DATIENT NAME PATIENT ACCOUNT NO. I ADMISSION DATE!DISCHARGE DATE' BILLING DATE _G 1 2,116 F i C A T H 1:R I N C I i 10 C" o 4 3UARANTOR INSURANCE COVERAGE POLICY NUMBER GRjo.)'fA'*--;ER DAN I Fl- LIFE 05 E,,7-** 160'? ALICANTS CONICIT'D CA 9 45::1 SERVICE DATE SVC.CODE DESCRIPTION CPT CODE ary AMOUNT 700i-"'4 2,0 Ft C:A'-SC:AF:.'.s4l SAi3RADA L11,; 1 1 i5lT Ci 1-*k A I N 0 F*k'�C AT 70:_)17C-17 MILK OF llA-'?--J---rSlA SU1-:-"l'- 11/0 4 81:. G 11 N G K 1-%, A 7 7' 1 TRIAZOLAM - :1 ;C,:RA 1 i 4 4 i 7( -W. t*m-"-) lir-o"L 51 1 7G+: 1 t- MV"f'E*F,'JlF)lM. INJ Ulhj:.: IML 10'0MG 4 41 Qi-1 i b L 1 D A N' U. Cj I Nl,,, ':A 71' f 4 r C:A I. TI IEF ftic". 0 0 d -i�r,,P AD "M Pk"/S!y� 0 uNL 4. 1i H R F-A D P I'S to, I ME Cj-77LJl-;/r-,FMt2 Pf" 1 41 Qu A S,--1 T"fANT I Gjpj'i' TRA TN' NG 2 6 F L 1!,,' 7 1 C iN A i TR I i,.I 11 L7,' I S, 7 R"i A.-Z t'-I L A 11 2 E'M G'rl-?�,.I N G"LE:P11,i CA 41 7 C►R K.NCL E 1 7C),Y- D.I A:r-F.-A 1,i 1 0 R A L.. D t tDl t'-4(D MF 1"F: IN j I Ill 17-- 4 42 0 G; G r'A I N CiF:I-N'i _:.AT it / i 7 ;GkAl5.5 , Wi'-' C:A-� IC I I t' 7 5 9 V 1--:0 C'I N, Ll� GRA N(:i!-R'i CA7 4 H,,,s i C:A I. rl I M 2�C 1 30.00 C 5'18:: 4 6-4 )4 ;',L,A� -':;LF' r—*'*r':r-i 8 9*ZI 85 C)--)t'0 15 GAIT EX%ERCISE 5 1 Z-41 10 1 7 0 0 ZY.'?13- TF;.'lAZ'-LA14 O,Z*51M','-� I 701:3 :-f31 ;GRA,"NGEF',*-j'L:AT 1 65 I I/0. L 7 Q Q42'G:c;551 VICODIN UF1 ;GRAIW�C-RqCAT 4 C-•.921 1 1"0 1*,-;l 8, 85'•!':j 9 1.71 1p 3 '-," I :.00. 0 r?HYS I CAL THER M w �: I I%'x::17 8: 7001 f:.'083 liFf- LOU' PLS' 10011-1 -X7.3 ' ; I NGK-l'%,9 CAT 11 7001. 11 MFTIOCLOPRAM 101NJ .4 :48 40 ;GRAINGF'RiCAT I 'A o 8 k"" 70(.-)'_7:-;:1*3 TRIAZOLAII ;GRA INGER-jCAT 2 4 J J 1 8500-:4001 EVALUATION, AND PLAN H J 0 C-'*�Lc,4045 TOTAL INDICATE AMOUNT ENCLOSED AND RETURN TOP PORTION WITH YOUR REMITTANCE. TOTAL CREDITS INCLUDE PfflENT ACCOUNT NUMBER ON YOUR CHECK. TOTAL DUE RETAIN BOTTOM PORTION FOR YOUR RECORDS. ESTIMATED INSURANCE COVERAGE HOSP FED.VkX NO.944003847 )R LABORATORY SERVICE DESCRIPTION PROCEEDED BY A LETTER,SEE M, ES1 IMATE'D PATIEW DUE VERSE SIDE OF BILL FOR IDENTIFICATION OF REFERENCE LASS. -D' CA i L CFrii'E L .,EASF DE JAC HAT PERFORAIION ANDREI URNWi I H YOUR RE W I TANCE PAGE i K-aer,c: i i O y CA F..4 1-1 AMOUNT ENCLOSED TYPE -J FINAL I INP ATIENT NAME PATIENT ACCOUNT NO. ADMISSION DATE i DISCHARGE DATE! BILLING�DATE tv(iE i C AT t j N E i H UARANTOR INSURANCE COVERAGE POLICY NUMBER Ij G R A t iJI 1,;-,F R i D A I I L MiF.*TRL-;P-0L.]TAN LIFE 5LC`-5 i'15 7- 1 -11 c:cIrq;..*:cIi`J) CA 94to—, Ij SERVICE DATE SVC,CODE DESCRIPTION CPT CODE j OTY AMOUNT o Fit iY L TL ME, 7*"t,,:� Fl!Yi:" JCAL. 'THER Mme; FIDi j T TT IN, : tYll J.�J r li S!I P P racy G F. Li C :'1 4 11 j I NIE I N,j 'I Cl 0 M L-3 G 1 Z,T 700, . 10 T'HER ME, _;o( m)- 1 4 1' M, E.�M T Pk P.1 lofyi • 41 r .0(_ I 1 1D jC*Z I ME U', I IS f:-.,fyi I F'k i ROOM, 42 41 0C C) TT)NG G 'T 5Z 4 j -fT!'+JA_. T R A P•Q r� i: . 5'2.44 1 .1 7 0 5 M E.1 E i I 1'.1 W". IFS,, 1 N!"'D 4 41 .c:1;_ ;ON All NGE 1:\i ii,'A T J 7t' 17 M I Lil- ., m- - ist-, 70i of �W\J�1717A 7 rYi 11) G P A T�IN S E R. C A, 4 7 H T R ryt'�71 C r'ITTlvjG I S;.: E:r7.o C)` ,i.i:rtl FVikLZJA'!'-I0rt 4t4D PLAJ'� I Z6" GAIT 7 i'A) N' 1.4-.3 5Z 44 ():n FU NC,r r(IN AL T P f--.) I,!I Ni, 5;7.44 6170_ FUKJ.C'!-I ONAL TRA I N IN(-,* -5;_.44 F -7- E:Uo():=()o I GAIT I NA)NIP NG -5'Z 44 4 6()'51 C,':;0 C L).-I"S I/Z" 1 4 2 Zf- III (_11 /(.Y-I./S�.: 4 6. �i Z10)7 k E,' J VC 1 1 APLE 1 10 CLIDS 4 Z Z Z 1 o,-*)c� J. MEl)-',-l'U!-:/,e:'jEMT pk ;R(11_1M 1 416, 00 TRAININ(i I 1 4 f-'ITTING z 5_2 44 1 � /,-14 GATT TLAISII NG Fj'7-' 4 4 TOTAL INDICATE AMOUNT ENCLOSED AND RETURN TOP PORTION WITH YOUR REMITTANCE. TWAL CREDITS INCLUDE PATIENT ACCOUNT NUMBER ON YOUR CHECK. TML DUE RETAIN BOTTOM PORTION FOR YOUR RECORDS. ESTIMATED INSURANCE COVERAGE HOSP FED.TAX NO.944003847 3R LABORATORY SERVICE DESCRIPTION PROCEEDED BY A LETTER,SEE IMATED PAI IENI DUE EVERSE SIDE OF BILL FOR IDENTIFICATION OF REFERENCE LASS. ORATION AND RETURN Willi YOUR Rf MIT lAt4(-'f '-----''--- Pi LA,,F Di-TACH AT 8ox PAGE CA 94i44 | t F N AL 2ATIENT NAME PATIENT ACCOUNT NO. ADMISSION DATE D111 LLING DATE 3UARANTOR INSURANCE COVERAGE POLICY NUMBER SERVICE DATE SVC.CODE DESCRIPTION CPT CODE OTY AMOUNT 5 Ms 75 AT ' � TarAL INDICATE AMOUNT ENCLOSED AND RETURN,TOP PORTION WITH YOUR REMITTANCE. TOTAL CREDITS INCLUDE pArIswTACCOUNT NUMBER omYOUR onsox - TOnALnws RETAIN BOTTOM PORTION FOR YOUR RECORDS. ESTIMATED INSURANCE COVERAGE °oapFED.nmNO.mwmmo80 owumm»nmOnySERVICE DESCRIPTION PROCEEDED evA LETTER,SEE swsnoeSIDE mpBILL FOR/nemnrw-4mowopREFERENCE LASS. --- --'-- r ---' - --- ----- -------------